Certificate Request

Certificate of Insurance Request

• Insured Information
• Insured Name
• Contact Name
• Address
• City
• State
• ZIP
• Phone
• Fax
• Email
• Certificate Holder's Information
• Recipients Name
• Attention
• Physical Address
• City
• State
• ZIP
• Phone
• Fax
• Email
• Job Reference (if any)
• Email to recipient email? - Please select - Yes No
• Fax to recipient fax? - Please select - Yes No
• Certificate Information
• Policies to be listed: General Liability Automobile Workers Comp (see special note if assigned risk) Umbrella Other
• If other, please list
• Additional Insured Required - Please select - Yes No
• If yes, Additional Insured Name and Address
• Certificate Transmittal Instructions
• Deliver to: Holder email Holder fax Insured email Insured fax
• Copy to: Insured email Insured fax
• Special Instructions
• For Assigned Risk Workers Compensation policies must have following information as these certificates are issued only by the assigned risk carrier – please allow 24-48 hours for these special certificates:
  - Physical address (P.O Box is not acceptable)
• Disclaimer: Please be advised that no changes to your policy will be made based on your certificate request or put into effect over the Morrill Insurance Brokerage website.