Certificate of Insurance Request Form Online

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What It Means to Be a CIC - The Certified Insurance Counselor (CIC) designation is a distinction that represents a commitment to professional excellence and leadership within the insurance industry. The 30,000+ designated CICs across the country are recognized as among the best and most knowledgeable insurance practitioners in the nation. The formal training required to become a CIC includes 100 classroom hours and the successful completion of five comprehensive exams, with an annual update required to ensure that CICs maintain their edge as the most capable and current insurance practitioners in the industry.

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	RUSH	Need by:

Today's Date:	12/22/2010 12:12:23 AM CST
Account Name:**
Account Number:
Your Name:**
Your Phone:**
Name Insured:
Name Insured (cont.):
For Division/Location:
Revision To Cert ID #:
Certificate Holder:
Address:
Address 2:
City, State ZIP:
ATTN:

** Required Fields
_________________________________________________________

Indicate type of policy:

US Domestic

Canadian

Coverages:	Limits: ** Required When Coverages Checked
General Liability
Worker's Compensation
Umbrella
Automobile Liability (provide description below)
Automobile Physical Damage (provide description below)
Property/Contents (provide description below)
Equipment (provide description below)
Other:

Description:

_________________________________________________________

Issue Automobile Identification Card State:
Include Description
_________________________________________________________

Special Instructions:
ONE TIME/EVENT CERT - DO NOT RENEW
Additional Insured( GL / Auto / Prop / Equip / UMB/EXC)
Loss Payee / Mortgagee / Lenders Loss Payable
Primary / Non-Contributory( GL / Auto / Prop / Equip / UMB/EXC)
Waiver of Subrogation( GL / Auto / WC / Prop / Equip / UMB/EXC)
Cancellation:
Other:

Handling Instructions:

E-mail to Certificate Holder @
Email to me @
FAX to Certificate Holder @
FAX to me @
Other:

_________________________________________________________

Comments:

Attachment:

To download a copy of the certificate request form either in Adobe's PDF format or in Microsoft Word format, click on the appropriate icon below.