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Request a Certificate of Coverage
Certificate of Coverage Request
A member of our staff will respond to your request.
Date
(Required)
MM slash DD slash YYYY
Type of Certificate of Coverage Request
Please select all coverages that apply. Use the SHIFT button to select more than one option.
Workers' Compensation
Liability
Property
Auto
APD
Entity Name Requesting Certificate
(Required)
Group or JPA Coverage Entity Name:
Name
(Required)
First
Last
Phone
Email
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Name of Certificate Holder
(Required)
Certificate Holder Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Certificate Holder Contact
(Required)
First
Last
Email
Phone
Fax
Description of event or activity for which coverage is being requested:
(Required)
Begin date of event or activity
(Required)
MM slash DD slash YYYY
End date of event or activity
(Required)
MM slash DD slash YYYY
Limits of Liability being requested
(Required)
Additional Covered Party?
If there is an additional party being covered, please provide documentation such as a contract or lease agreement which clearly indicates the insurance requirements
Yes
No
Waiver of Subrogation Requested (Workers' Compensation only)
(Required)
If there is a waiver of subrogation, please provide documentation such as a contract which clearly indicates the insurance requirements.
Yes
No
Is Property Coverage being requested?
Yes
No
Total Value of Property Coverage being requested (amount required if Yes)
Is Loss Payee Required? (Property only)
Yes
No
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