Request For Additional Insured
Reason for request:
Additional Insured
Certificate of Insurance
Your Company Info
Customer ID Number
(Provided by Cossio - Do Not Enter Your Policy Number)
Company Name
Company Phone
Additional Insured Info
Relationship
Landlord as Additional Insured
Verification of Insurance Only
Mortgagee as Additional Insured
Additional Insured
Loss Payee
Employee As Lessor
Lienholder
Concessions
Government Agency
Booking Agent/Entity
Contractor
Name of Addit Insured
Contact First Name
Contact Last Name
Street
City, State Zip
Phone
Fax
Email
Event Date And Location
Start Date (xx/xx/xxxx)
End Date (xx/xx/xxxx)
Street
City, State Zip
*** 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. ***
PLEASE ALLOW AMPLE TIME FOR PROCESSING AS SOME CERTIFICATES MUST BE ISSUED BY THE CARRIER AND NOT BY COSSIO INSURANCE AGENCY. IT COULD BE 5 - 10 BUSINESS DAYS OR MORE DEPENDING ON THE INSURANCE COMPANY'S WORK FLOW