Certificate Request - Cross Insurance Agency

Certificate of Insurance Request

Please complete the form below if you are needing to request a certificate. These certificate requests are handled on a priority basis.

Once the certificate has been generated along with any other appropriate forms, it will be sent via email to the certificate holder and to our named insured.

Requestor Information

Your Company Name: *

Your Name: *

Email *

Phone *

What is your relationship to the Named Insured? *

Recipient Information

Company or First & Last Name *

Certificate Holder Information

Certificate Holder (Full Business Name) *

Address *

Address Line 1

City

State

Zip Code

Phone

Email *

Is there an executed written contract requiring an Additional Insured? *

Description & Other Information

Project/Event? Job Name (If Applicable)

Type of Coverage: Select all that apply

Type of Coverage: General Liability

General Liability

Type of Coverage: Auto

Auto Liability

Type of Coverage: Cargo

Cargo

Type of Coverage: Excess

Excess Liability

Type of Coverage: Workers Comp

Workers Comp Liability

Type of Coverage: Other

Other

Other information for agent:

Please upload a copy of the contract or sample certificate if available:

Click or drag a file to this area to upload.

Upload Document

Acknowledgement *

I acknowledge that coverage is not bound by submitting this request. I will be contacted via electronic confirmation when the request has been processed.

Phone

44838

Certificate of Insurance Request

Requestor Information

Recipient Information

Certificate Holder Information

Description & Other Information

Type of Coverage: Select all that apply

Location

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