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Certificate of Insurance (COI) request form
Your Contact Information (The name of our insured)
This section is for the person or business that we insure.
Contact Name (Our Insured)
*
First
Last
*
Indicates required field
Your Company Name (Our Insured)
*
Email (Our Insured)
*
Certificate Holders Information
This is the person or company (our insured) is sending the certificate to (Certificate Holder).
Certificate Holders Name
*
Enter the individual or company name of the certificate holder
Certificate Holders Email or Fax Number
*
In order to notify the certificate holder, we must have either their email or fax number. We do not mail out certificates by regular mail.
Certificate Holders Address
*
Line 1
Line 2
City
State
Zip Code
Country
Notes
*
Additional Endorsements Needed for General Liability
*
Additional Insured
Waiver of Subrogation
Primary & Non-Contributory
Other
These endorsements may have a charge associated with them by your insurance company. We will contact you for payment if required. If Other, list in the notes box the specifics.
Additional Endorsements Needed for Business Auto
*
Additional Insured
Waiver of Subrogation
Hired & Non-Owned Auto
Addtional Endorsement Needed Work Comp
*
Waiver of Subrogation
In order to add a waiver of subrogation to your work comp. You need to upload or email a copy of your contract showing the waiver being requested as well as the total cost of the contract. It can take the company up to 21 days to process it.
Our certificate department processes three batches each day and most request are sent within a few hours of receipt. However, we endeavor to send out all request that are made by 10AM Eastern time by no later than 5PM Eastern time. If your request is lengthy or requires special endorsements or wording, we may have to contact you prior to sending.
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