Certificate of Insurance Form

Name(Required)

First Last

Phone Number(Required)

Email(Required)

Company Name(Required)

Address 1(Required)

Address 2

City(Required)

State(Required)

Zipcode(Required)

Policy Number

Certificate Holder(Required)

Certificate Holder Address 1(Required)

Certificate Holder Address 2

Certificate Holder City(Required)

Certificate Holder State(Required)

Certificate Holder Zipcode(Required)

Certificate Holder Email

Email Copy To

Mail original to certificate holder?

Yes

Does certificate holder require to be listed as "Additional Insured"?

Yes

Are you insured through POWERS or Leif?

POWERS® Insurance & Risk Management

Leif Assurance

If available, please provide a copy of your insurance requirements?

Max. file size: 39 MB.

Are there any additional requirements to include on the Certificate?

Primary and Non-Contributory or Waiver of Subrogation

Would you like to receive text messages?

I give POWERS® Insurance & Risk Management permission to send me SMS text messages.

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