Certificate of Insurance Request Form (Basic Cert)

Certificate of Insurance Request

ISC Use for Basic Certs (no additional insureds, etc)
This form is for BASIC certificates of insurance only.

If the certificate requires additional insureds, waivers of subrogation, shortened notice of cancellation or any other specific requirements, ask the caller to:

-email us a copy of the contract/paperwork with the certificate requirements (preferred method) OR

-transfer the caller to an Account Manager (not preferred)
YOUR Email (email address of ISC staff person completing this form)*
example@example.com
Caller's Name*

First NameLast Name
Client Name
Caller's Phone Number

Area CodePhone Number
Certificate Holder: (Who the client wants the certificate to be sent to):
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email for Certificate Holder: if they don't have this information you can offer to call the company to get the information - otherwise have caller find it and call us back:*
example@example.com
Project or Job Number (optional)
Description of Project/Job (optional):
Example: Snow removal, new roof, remodeling project
Special Instructions:
* Please note, a written-contractual obligation must exist for certain coverages to apply. If you do not have a written contract with the certificate holder, please call your agent to discuss this matter. Additional fees may apply to add these extra coverages.
By clicking “submit” you acknowledge your understanding that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY. Endorsements or special wording will require additional processing time and may increase insurance premiums. All contracts should be reviewed by your legal counsel.
Should be Empty:

Certificate of Insurance Request

Certificate Holder: (Who the client wants the certificate to be sent to):