Certificate of Insurance Request Form 2017-02-03T21:23:26+00:00

Certificate of Insurance Request Form

(Download print version here.)

 

Contact Information

Moody Insurance Client Information

Certificate Holder Information

Individual, Company or Organization to Whom We Will Provide Evidence of Coverage
Certificate of Insurance will be issued as entered below
Either Fax OR Email required

Special Requirements and Endorsements

Cancellation Notice Requirement

Additional premium may apply.

Project Information

Required for Additional Insured and Waiver of Subrogation

Upload Contract and Other Documents

Comments, Notes, and Special Instructions

Sending

SPECIAL REQUIREMENTS AND ENDORSEMENTS INFORMATION:

EVIDENCE OF INSURANCE ONLY

Provides evidence of the insurance coverage you currently have in force for you and your business only. In the event a third party needs to be added, please see Additional Insured.

LOSS PAYEE

If your Vehicle or Property is financed, the financial institution may request that it be added as a Loss Payee on your Certificate of Insurance and Policy. In this case, if the Certificate Holder is requesting to be added as Loss Payee, its interest in your Vehicle or Property will be included in the payment of the claim.

MORTGAGEE

If there is an entity which holds a mortgage on your Business Property, it will need to be included on your insurance policy as a Mortgagee. If a loss should take place while the mortgage is outstanding, the Mortgagee has the right to be compensated for the damages through your property policy.

ADDITIONAL INSURED

As part of your business dealings you may be asked to provide coverage for a customer or higher-tier contractor by adding the customer to your policy as an Additional Insured. This extends coverage to your customer. If this box is checked, it is possible that your policy will need to be endorsed to add this entity as an Additional Insured. Please be advised that there may be additional premium required for this change.