Certificate of Insurance Form Name(Required) First Last Phone Number(Required)Email(Required) Company Name(Required)Address 1(Required)Address 2City(Required)State(Required)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 PacificZipcode(Required)Policy NumberCertificate Holder(Required)Certificate Holder Address 1(Required)Certificate Holder Address 2Certificate Holder City(Required)Certificate Holder State(Required)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 PacificCertificate Holder Zipcode(Required)Certificate Holder Email Email Copy ToMail original to certificate holder? Yes No Does certificate holder require to be listed as "Additional Insured"? Yes No Are you insured through POWERS or Leif? POWERS® Insurance & Risk Management Leif Assurance If available, please provide a copy of your insurance requirements? Drop files here or Select files Max. file size: 39 MB. Are there any additional requirements to include on the Certificate?Primary and Non-Contributory or Waiver of SubrogationWould you like to receive text messages? I give POWERS® Insurance & Risk Management permission to send me SMS text messages. hCaptcha(Required)
