FLEX - Certificate Request Form

Name of Organization/Business as It Appears on Insurance*

Name of Person Requesting Information*

Please Note: If you are not the primary or alternate contact on the account, documents will be sent to the primary contact listed in our files.

Phone*

Email*

What Can We Help You With Today?*

Please describe any changes that need to be made to your current certificate. Please include the name of the entity listed on the certificate.

Check the type of certificate you are requesting*

Certificate holder information:

Entity Name:*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Please attach the certificate requirements if needed:

Max. file size: 256 MB.

Relationship to named insured:*

Other than being named on the certificate as an additional insured/certificate holder, does the entity require any special wording or endorsements?*

SPECIAL COVERAGE REQUIRED BY WRITTEN CONTRACT*

Other:*

Special certificate language needed (please explain, if applicable)

Are you requesting this certificate for a special event?*

Date(s) of event/activity:*

Hours of event/activity:*

ex: 12 p.m. - 4 p.m.

Type of event/activity*

Name of event/activity:*

Location of event/activity:*