Additional Insured Certificate Request
Welcome! This is our new Additional Insured Certificate Request form. Here is a simplified way to submit your additional insured certificate requests.
*NOTE* CERTIFICATES WILL BE RETURNED WITHIN 24 HOURS UNLESS SUBMITTED ON FRIDAYS. FORMS SUBMITTED ON FRIDAYS CANNOT BE GUARANTEED DAY-OF RETURN.
If you have any questions, please feel free to send me an email:
Request Coming From:
Certificate Holder Individual or Company Name
What is the name of the Company or Entity to be listed as the Additional Insured on the COI? In other words, who is requesting this Additional Insured COI from you?
Certificate Holder Address
What is the address of the Company or Entity to be listed as the Additional Insured on the COI? IF YOU NEED A BLANK COI FOR PROOF OF COVERAGE ONLY, PLEASE ANSWER "BLANK COI" BELOW.
Certificate Holder City
Certificate Holder State
Certificate Holder ZIP
Description of Operations/Locations/Vehicles
This is for any specific wording requested by the Holder. Example: "Certificate Holder is listed as additional insured". Feel free to Copy + Paste information as necessary.
(please check all that apply)
Additional Insured on General Liability
Additional Insured on Automobile Liability
Waiver of Subrogation Required for GL
Waiver of Subrogation for Auto
Waiver of Subrogation on Workers' Compensation
Send Additional Insured Certificate To:
If the Certificate Holder requires a direct copy of of the COI from us, please insert their email below
OTHER: Please include any specific requests, requirements, or questions regarding the certificate, here:
Example: "Holder requires A-rated endorsement for General Liability". Feel free to Copy + Paste any wording specific to additional requests required to complete this AI request.
Send me a copy of my responses.
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