Certificate of Insurance Request COI Request Step 1 of 7 0% Name* First Last Email* Phone* Named Insured*Policy Number* Type of Certificate Requested*Proof of Coverage ONLYAdd Additional Insured as requested by contractAdd Additional Insured w/special wording Which policies are required to be shown* General Liability Commercial Auto Worker's Comp Excess Liability/Umbrella Professional Liability Other Select all that apply Certificate Holder Name*Please list the certificate holder information EXACTLY as required on the COICertificate Holder Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Certificate Holder Email* Additional InformationPlease provide any special wording required by the Certificate HolderCAPTCHA Consent* I agree to the following:By submitting this request you are authorizing Leal Insurance Services, LLC, to submit any endorsement request to the carrier only the policies designated above as required to meet the requirement of the Certificate Holder and submit the COI - on your behalf - to the Certificate Holder. Submitting this COI request does not constitute a binding confirmation of a new or revised insurance coverage. Please allow up to 1 business for an agency representative to contact you.
