Certificate of Insurance Request
Name of Policyholder:
Name of Certificate Holder:
Which best describes the nature of Named Insured's business with Certificate Holder:
a. is performing or performed work for or on behalf of certificate holder
b. leasing or renting a premises from certificate holder
c. is purchasing a product from certificate holder
d. is leasing a machine or other business products from the certificate holder
e. is leasing a vehicle from the certificate holder
g. trailer interchange transport agreement
f. transporting cargo
h. other
Is Trailer Interchange Comprehensive and Collision coverage required?
Yes
No
Is Cargo coverage required?
Yes
No
What limit of Cargo coverage is required?
Please Select
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Greater than 100,000
What limit is required for Trailer Interchange Comprehensive and Collision?
Please Select
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Greater than 100,000
Please describe the nature of your business with the certificate holder:
In reference to Certificate Holder, please select which applies below:
No Special insurance requirements apply
Include as Additional Insured (based on verbal request rather than a written agreement)
Include as Additional Insured (based on written agreement between you and a third party)
Please indicate any additional requirements below which apply to Certificate Holder:
Limit Additional Insured status to apply only to ongoing operations (ends once work is completed)
Include as Additional Insured to also include completed operations (continues after work has been completed)
Include as Additional Insured for Auto Liability
Refer to uploaded document(s) for details (optional)
Other
You can upload any documents or pertinent information here:
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of
Mailing Address of Certificate Holder:
Send Certificate to (mark all that apply):
Certificate Holder
Policyholder
Both
Other(s)
Please provide information regarding where we should send the Certificate:
Send to Certificate Holder by:
Postal Mail
Fax
Email
Other
Email Address:
example@example.com
Fax Number:
Please enter a valid phone number.
Describe other method of preferred delivery:
Please note any other requirements below or upload a copy of the contract for our evaluation:
Are these insurance requirements part of a written agreement?
Yes
No
Additional Instructions or comments:
Name of person who completed this form:
By submitting this form you agree the information was completed by you and to the best of your knowledge.
Your Email Address:
example@example.com
Submit
Should be Empty: