Certificate of Insurance Request Step 1 of 7 0% Your Name:* First Last Your Email:* You Phone Number:* Policy Holder's Name* Policy Number* Type of Certificate Requested* Proof of Coverage ONLY Add Additional Insured as requested by contract Add Additional Insured w/special wording Which policies are required to be shown* General Liability Commercial Auto Worker's Comp Excess Liability/Umbrella Professional Liability Other Select all that applyAny changes in operations?* Yes No Please advise if there have been any changes in your operations, ownership or organizational structure since the start/renewal policy term.Any changes to drivers or vehicles?* Yes No Please advise if you have hired any new drivers, need to remove former drivers or have added any new vehicles. 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* Street Address Address Line 2 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 List the address for Certificate Holder listed above.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.CAPTCHA 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 1-2 hours. If request is received after-hours, COI will processed next business within 1-2 hours of opening. If provided with incomplete information, it WILL delay COI issuance.