Certificate of Insurance Request
You have the option of requesting Certificates of Insurance on the following electronic form. It is important to include as much information as possible. We will review your request, contact you if further information is required, and then send the certificate of insurance to the appropriate party(s).
Your Business Name:
Effective Date for Certificate:
Certificate Holder: (Name & Full Address)
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Does Certificate Holder need to be listed as Additional Insured?
*Complete Description of Project including job name, job number. This is critical. We cannot proceed without this data.
*Include a copy of your contract & the holder's insurance requirements along with this form. *Certificate of Insurance will be provided within 48 hours of receipt of required documents. *This is critical. We cannot process the certificate without this data.
C-105.2 Required? (The C-105.2 is usually required by municipal entities)
Additional wording being requested:
Please mark all additional items needed:
Thirty Day Cancellation
"Endeavor to" wording deleted
Please attach written request(s) and/or contracts received, if any.
This field is for validation purposes and should be left unchanged.
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April 28th, 2014
Lighthouse Insurance Agency, LLC