• Certificate Request by Cossio Insurance Agency
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Certificate Request Online Form


REASON FOR REQUEST    
Your Company Information      
Customer ID Number: (Provided by CIA) Company Name:
Company Phone Number: (xxx)xxx-xxxx Company Email:

Additional Insured Information    
Relationship:  
Name of Additional Insured:
Contact's First Name: Contact's Last Name:
Street Address:
City, State, & Zip Code:
Phone Number (xxx)xxx-xxxx : E-mail Address:
Fax Number (xxx)xxx-xxxx :

Event Date and Location      
Start Date (xx/xx/xxxx): End Date (xx/xx/xxxx):
Street Address:
City, State, & Zip Code:
Is the city requesting and endorsement? Yes No

If you need a rush certificate, call our office AFTER you have submitted the information.

*** NOTE : Requests for additional insured listings may be subject to a fee as determined by your insurance carrier. This fee must be paid before the certificate is issued. ***