America's Workers Compensation Headquarters

Certificate Of Insurance Requests

When we issued your policy what name was it issued to ?*
Your Name*
Your Phone Number*
Your Email Address*

General Liability Certificate Request

General Liability Holder Name
General Liability Holder Address
General Liability Holder City
General Liability Holder State
General Liability Holder Zip

Certificate Only
Additional Insured (a fee may apply)
Waiver of Subrogation (a fee may apply)
Other

Please type any Special Request For General Liability endorsements such as waiver of subrogation or additional insured keep it mind most carriers charge at least $100.00 for waiver of subrogation or a additional insured endorsement.


Workers Compensation Certificate Request

Copy Information From Above

Workers Compensation Certificate Holder Names
Workers Compensation Certificate Holder Address
Workers Compensation Holder City
Workers Compensation Holder State
Workers Compensation Holder Zip

Certificate Only
Other

Keep in mind of the only endorsements your can add to workers compensation are the ones I listed below. You cannot have a client named as additional insured for workers compensation only general liability

Waiver of Subrogation
Alternate Employer Endorsement
Defense Base Compensation Act
USL & WH
Outer Continental Shelf Lands Act
Non-Appropriated Fund Instrument Act

Any Special Instructions for your workers compensation certificate please list below

Enter the code as it is shown*