Certificate of Insurance Request Policy Holder Information SectionPolicy Holder's Name*For which policy are you needing a Certificate of Insurance (COI)* General Liability Auto Liability Umbrella/Excess Liability Worker's Comp Professional Liability/Errors & Omission Your Name:* First Last Email* Phone*Type of Certificate Requested* Proof of Coverage ONLY Add Additional Insured as requested by contract Add Additional Insured w/special wording Any changes in operations?*Please advise if there have been any changes in your operations, ownership or organizational structure, including any employees (drivers) since the start/renewal policy term. Yes No Certificate Holder InformationThis is where you'll tell us who is requesting the this information from you.Certificate Holder Name*This is person/contractor/entity that is requiring a copy of your coverages. Please list the Certificate Holder information EXACTLY as required.Certificate Holder Address*Please provide the address for Certificate Holder shown above. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Certificate Holder Email* Additional InformationPlease provide any special wording required by the Certificate HolderIf the Certificate Holder has provided you with a sample certificate including their requirements, please upload it here.Accepted file types: jpg, png, pdf, Max. file size: 25 MB.Consent* I agree to the following:By submitting this request you are authorizing My Insurance Group to submit any endorsement request to the carrier only on the policies designated above as required to meet the requirement of the Certificate Holder and submit the COI - on your behalf - to the Certificate Holder. Submitting this COI request does not constitute a binding confirmation of a new or revised insurance coverage. Usual processing time for COI request received during normal business is 3-4 hours. If request is received after-hours, the COI will be processed the next business day within 3-4 hours of opening. Providing incomplete information could delay COI issuance.CAPTCHA
