Request For Certificate Of Insurance
Fill in the following information to request a certificate of insurance, whether to add loss payee or additional insured or to provide verification of coverage. After you submit this information the certificate will be printed and sent to all required parties.
(If you have any questions about this or are unsure how to fill out the form, please call us for assistance at the number listed here.)
Your Name:
Your E-mail Address:
Certificate Holder Name:
Certificate Holder Fax Number:
Street Address:
City:
State/Province:
Zip/Postal Code:
Do you want to add an additional insured or loss payee to the policy,
OR, provide verification of coverage only?
To which policy types should the certificate refer?
(If unsure, please call for assistance at the number listed below)
Garage Liability
Property
Automobile
Workers Compensation
If this policy includes business property coverage, please indicate
whether it has, or doesn't have a serial ID number.
The issuing company will endeavor to mail 10 days written notice to the certificate holder.
If you need a notification time earlier than 10 days, please enter the number of days notice required:
Additional comments or information:
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None of the information in this web site should be construed as legal or insurance advice. All forms, policies, terms, information and procedures should be reviewed by your legal counsel before being
used in any way. Copyright © 2004 DIS
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