Certificate of Insurance Request Form

Certificate of Insurance Request

More than 3,000 Cert Processed Annually
We processed more than 3,000 certificate of insurance requests yearly. Most (98%) were done the same day.

We pride ourselves on prompt response to requests for certificates of insurance. This form has been developed to obtain the information needed to evaluate and process the request.

A Certificate of Insurance is used to provide proof of insurance coverage to a certificate holder. The insured may be required by a contract to add the certificate holder as an additional insured.

If the requirement of the certificate comes from a contract or lease, please up load a copy of the contract or the section of the document that outlines coverage and wording requirements.

Certificates order before 12PM are issued by the end of business that day.

Certificates order after 12 PM are issued within one business day.

Please call us at 312-341-9080 x"0" if you have not received your certificate within that time frame.

Matthew H. Cooper
President
Community Insurance Center,
a div. of Inner-City Underwriting Agency Inc.
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Name of Person Requesting Certificate

First NameLast Name
Phone Number

Area CodePhone Number
Named Insured
Type of Certificate being Requested

Mortgagee - Evidence of Property InsuranceMortgagee - Certificate of Liability InsuranceLandlord - Certificate of Liability InsuranceConstruction - Owner/GC - Certificate of Liability InsuranceMunicipality - Certificate of Liability InsuranceOther - Certificate of Liability InsuranceOther - Evidence of Property InsuranceCondo Unit Owner Evidence of Insurance
If Special Wording Required - Type it Below
If Cert ificate is required for Construction Project , Describe Project
Dollar Amount of Contract
Certificate Holder Inforamtion
Full Name of Certificate Holder
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload copy of contract or document that outlines insurance requirements.

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Certificate of Insurance Request

Certificate Holder Inforamtion