Certificate of Insurance Request Form

Please review the below instructions on requesting a Certificate of Insurance and completing the Certificate of Insurance Request Form.

General Guidelines

  •  Most certificates are issued within 24-48 weekday hours. Special requests and incomplete forms may take longer to process.
  • Many organizations that request a certificate of insurance also request “additional insured” status. An “additional insured” is a person or organization that is not automatically included as an insured under your insurance policy, but for whom limited insured status is arranged. Additional Insured statue does not extend full general liability insurance coverage to the other entities, but rather provides limited coverage for that entity in the event a claim arises from your organization’s acts or omissions. However, an additional insured is not covered under your policy for its own acts or omissions. To protect itself from such claims, the additional insured would have to secure its own general liability policy.
  • In order to name an organization as an additional insured, there must be a legal document that requires such status. The document may be in the form of a permit, contract or other type of agreement. If a claim occurs in which the additional insured requests coverage and no legal document exists, coverage for the additional insured could be denied. Such a denial could lead to claims of misrepresentation between the entity and your organization.
  • A common request of an additional insured is that your insurance policy be endorsed to serve as the primary insurance and that all other insurance of the additional insured becomes excess and noncontributing. Please provide Patriot Insurance Agency, Inc. a copy of such language for a review and response.

Insured Information

  • Enter your organization’s name and account number.
  • Please provide your name and contact information should we need to contact you for additional information.

Certificate Holder Information

  • Enter the name, address of the organization requesting a certificate of insurance from your organization.
  • Indicate whether the certificate holder is requesting to be listed as an additional insured.

If the Purpose of the Request is due to an Event

  • Provide the details of the event: date, name of the event, location, description.
  • If the event will have alcohol, please contact our agency at 800.859.2724.
  • If the event involves athletic participation, please complete the questions.

Distribution of the Certificate

  • Please note that a copy of the certificate is automatically sent by the mail to your organization.
  • Once you have received the certificate of insurance, ensure that this is accompanied with additional documentation such as permits, contracts, or other agreements and are maintained for at least five years from the date of the event. These documents can assist a claim adjuster and counsel in the event of a claim.

If you have any additional information you would like to convey, please add it to the comments field at the bottom of the Certificate of Insurance Request Form.