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Certificate of Insurance Request
"
*
" indicates required fields
Step
1
of
2
50%
URL
This field is for validation purposes and should be left unchanged.
Named Insured
*
Name
*
First
Last
Email
*
Phone
*
Additional Named Insured Email(s)
*
Separate email addresses with a semicolon ( ; ).
Request Type
*
New Request
Revision
Renewal
Frequency?
*
One Time Only (Special Event)
Annually
Date
2 years will be marked if no date provided.
Importance
*
Normal (within 24 hours)
Rush (ASAP)
Certificate Holder Information
Please insert the information of the company/person that is requesting this certificate.
Project
*
Certificate Holder Name
*
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Certificate Holder Email
*
Additional Certificate Holder Email(s)
Separate email addresses with a semicolon ( ; ).
Lines of coverage requested to be evidenced on certificate? (Check all that apply)
*
General Liability
Workers Comp
Auto Liability
Professional Liability
Property
Pollution
Excess Liability
Other
Other line of coverage
Any other insurance provisions/ special language requested?
General Liability Requirements
Additional Insured?
Waiver of Subrogation?
Primary Non-Contributory?
Check box for "Yes", leave unchecked for "No"
Workers' Compensation & Employers Liability Requirements
Waiver of Subrogation?
Check box for "Yes", leave unchecked for "No"
Auto Liability Requirements
Additional Insured?
Waiver of Subrogation?
Primary Non-Contributory?
Check box for "Yes", leave unchecked for "No"
Professional Liability Requirements
Waiver of Subrogation?
Check box for "Yes", leave unchecked for "No"
Property Requirements
Loss Payee?
Waiver of Subrogation?
Check box for "Yes", leave unchecked for "No"
Pollution Liability Requirements
Additional Insured?
Waiver of Subrogation?
Primary Non-Contributory?
Check box for "Yes", leave unchecked for "No"
Excess Liability Requirements
Additional Insured?
Waiver of Subrogation?
Primary Non-Contributory?
Check box for "Yes", leave unchecked for "No"
Delivery Method
Deliver to Requester
Deliver to Requester & Cert Holder
Supporting Documents
Max. file size: 8 MB.
Please contact your COI Specialist at
(770) 552-4225
or
*protected email*
with questions or concerns.
Consent
*
I agree to the
privacy policy
and statement below.
The information you enter in the message box above is not secured in transit. Please do not enter information that would be considered sensitive, confidential, or private such as social security number or other personal identification. EPIC will not be liable for any loss or damage including, indirect or consequential losses or damages, arising out of, or in connection with, information submitted through this website. Insurance coverage cannot be bound or altered via submission of this online form.
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