Instant Certificate Request (Eligibility Check Required) "*" indicates required fields Policy Number*Insured Contact InformationInsured Contact Email* Note: This must be the policy email address.Company Name*Insured Contact Name First Last Insured Contact Address* Street Address Address Line 2 City State 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 ZIP Code Certificate Holder / Additional Insured Information(This is the Business / Entity that is requiring you provide them a certificate)Certificate Holder / Additional Insured Full Name*Certificate Holder / Additional Insured Email Certificate Holder / Additional Insured Address Street Address Address Line 2 City State 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 ZIP Code Does the certificate holder need to be named additional insured?* Yes No Special Options*Please selectVerification of Coverage onlyAdditional InsuredAdditional Insured + Primary Non-Contributory & Waiver of Subrogation**Only endorsements that are currently included in your policy will accompany the COI.**Note: Some options will only return on the certificate if the appropriate endorsements are on the policy.Is this certificate for licensing?* Yes No Certificate Requested ByYour Full Name*Your Relationship to Insured*Attestation* By checking this box, I attest that I am an owner, officer, partner, member, adequately credentialed employee, or otherwise fully authorized representative of the Insured/Policy Holder (not the Certificate Holder/Additional Insured). As an official representative of the Insured/Policy Holder, I have reviewed my policy and affirm that my operations for this Certificate Holder/Additional Insured align with my policy provisions. Acknowledgement & Acceptance* By checking this box, I understand, acknowledge, and accept that any Certificate issued, is issued as a matter of information only; the Certificate Holder/Additional Insured language is displayed as a courtesy for your reference, but in no way does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policy(ies). I understand and accept that the policy(ies), not the certificate, is/are the definitive source of for its provisions and this certificate does not constitute a contract between the issuing Insurer(s), Authorized Representative or Producer (Gaslamp), and the Certificate Holder. PhoneThis field is for validation purposes and should be left unchanged.
