COI Request Form

You have the option of requesting Certificates of Insurance on the following electronic form. It is important to include as much information as possible. We will review your request, contact you if further information is required, and then send the certificate of insurance to the appropriate party(s).


    General Information

    Job Reference No.:
    Name of Insured:
    Name/Company of Certificate Holder:
    Address of Holder:
    State: Zip:
    Holder Phone:
    Holder Fax:
    Your Name:
    Contact Email:
    Handling Method: EmailFax

    Required Coverages

    Please provide copy of insurance requirements of contract:

    AutoUmbrellaGeneral LiabilityEquipmentWorkers' CompensationBuilders Risk

    Need Endorsements for Waiver of Subrogation: YesNo

    Need Endorsements for Primary Wording: YesNo

    Loss Payee: YesNo

    Mortgagee: YesNo

    Additional Insured: YesNo

    Comments or Other Instructions:

    Attach File

    Please attach written request(s) and/or contracts received, if any.


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    West Virginia

    “Insuring Our Community with Knowledge & Integrity.”

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    (610) 459-4444

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