Certificate of Insurance Insured InformationYour Name* Business Name Your Email* Your Phone Number*Client ID or Policy Number Certificate of Liability InsurancePolicies to Reference (Select All That Apply)* Select All General Liability Commercial Auto Umbrella / Excess Liability Workers Compensation / Employers Liability Do you need to add a certificate holder?* Yes No, I just need a proof of coverage. Do you wish to name the certificate holder as additional insured?* Yes No Do you need to reference a specific job or location on the certificate?* Yes No Job or Location Details*Special Wording or Endorsements (Check all that apply.)Depending on your policy, additional underwriting may be required. Primary Wording Waiver of Subrogation Other Do you have a sample certificate or insurance requirement that you would like to upload? Yes No Upload Insurance Requirements / Sample CertificatesMax. file size: 2 MB. Certificate HolderCertificate Holder Name* Certificate Holder Address* Street Address City State / Province / Region ZIP / Postal Code Certificate Holder Email* Certificate Holder Fax (if applicable)Is the certificate holder the only additional insured to be listed on the certificate? Yes No Please list all additional insureds.* Where should we send it? Insured Email Certificate Holder Email Certificate Holder Fax Certificate Holder Address
