Client COI Request Form

Disclosure

Please note that this form is used to request a Certificate of Insurance from our agency. Completion of this form does not bind or alter any coverage on your insurance policies.

Acknowledged Disclosure(Required)

I Acknowledge That I Read and Understand the Disclosure

Your Information

Name(Required)

First Last

Business Name

Phone(Required)

Certificate Holder Information

All fields are required. We cannot complete a certificate without this information.

Name to Be Listed on the Certificate of Insurance(Required)

Address to Be Listed on the Certificate of Insurance(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

The certificate holder will give you this, it may not be the same address as the job location.

Job Information

Job Description(Required)

Location of Job(Required)

Approximate Job Start Date(Required)

Approximate Job End Date

If no end date, is project ongoing? (Several Months)

Ongoing

Any Special Wording or Requirements? (or you can upload example below)

Sometimes a Certificate Holder will want all kinds of special wording or clauses written on your Certificate of Insurance. Sometimes an insurance company can meet those requirements, sometimes they cant. Also, many times the insurance carrier will charge extra for certain clauses. Don't worry, we will call you before making any changes to your policy that result in an additional charge.

Certificate of Insurance Requirements Example

Max. file size: 39 MB.

Where Should We Send the Completed Certificate? (Email Preferred)(Required)

Is There a Second Place We Should Send the Completed Certificate? (Email Preferred)

All COIs Have a 24 Hour Waiting Period

Urgent

If urgent is checked we will try to send it out quicker. Please use this when you really need it.

Comments or Additional Notes for Us