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Certificate of Insurance Request

Use this form to request a certificate of insurance (COI) for your commercial policy. Please provide as much detail as possible so the certificate is issued correctly the first time.

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Complete the general information, the certificate holder details and the coverages required by your contract. We issue most certificates the same business day.

General information

Name of insured *

Business / DBA name

Insured mailing address

City

State

ZIP code

Policy number

Insurance company name

Certificate holder

Certificate holder name *

Holder address

City

State

ZIP code

Holder phone

Holder fax

Your name *

Contact email *

Contact phone

Handling method

EmailFax

Required coverages

Please provide a copy of the insurance requirements of the contract.

Coverages required

AutoUmbrellaGeneral LiabilityEquipmentWorkers' CompensationBuilders Risk

General liability description

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

Attachments

Please attach written request(s) and/or contracts received, if any. Max file size 25 MB.

No coverage or premium adjustment is bound until you receive written notice from Horizon Insurance.

Horizon Insurance

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