AON Insurance Request Form

Insurance Request Form

Please complete this form to request an insurance certificate from AON.
Cohera Employee Submitting Form
Cohera Employee's Name*

First NameLast Name
Cohera Employee's Email Address*
First.Last@meetcohera.com
Recipient Email for Completed COI
AON will send the completed COI to this email address. Leave blank if AON should send the COI to the email address provided in the previous field.
Cohera Office*
For example: Arizona, SAT, Marketing, Boston, etc.
Program Name*
Put N/A if this doesn't apply.
Program Number*
Put N/A if this doesn't apply.
Is this a rush request?*

Yes, this COI is needed immediately.No, this COI is not needed until the below date.
Due Date*

MonthDayYear
Certificate Holder Information
Company Name*
DBA (Doing Business As) Name
Leave blank if N/A
Attention To
Leave blank if N/A
Company's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Cohera*

ClientHotelVenueLandlordOther
COI Information
Named Insured
Additionally Insured
Important Notes for Cohera Employee Submitting Request:
- If any type of coverage in the table below is not required, leave blank.
- Do not agree to any auto coverage (i.e. owned, leased, rented, etc.) other than Hire or Non-Owned.
- If you need any type of coverage not listed below, ask your supervisor.

Coverage & Limit Information*

Rows	Limit ($) $5M maximum for GL, Auto, Cyber, Umbrella $1M for ML, WC, Property
General Liability (GL)
Workers Compensation (WC)
Auto Liability (Hired or Non-Owned Only)
Professional Liability (E&O)
Cyber Security
Management Liability (ML)
Property
Umbrella Liability (Excess)

Description of Operations*

Rows	Yes/No
Waiver of Subrogation
Primary and Non-Contributory
Additionally Insured
Miscellaneous (i.e., Property Location, Description of Project/Contract Name and/or Number, Duration, etc.)

Additionally Insured Language (Provide exact wording to be listed)*
Put N/A if this doesn't apply
Additional Documentation

Cancelof
Auto renew this certificate next year?*

YesNo
Should be Empty:

Insurance Request Form