Cossio Insurance Agency

Certificate Request Online Form

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

Additional Insured Information
Relationship:	Landlord as Additional Insured Verification of Insurance Only Mortgagee as Additional Insured Certificate Holder as Additional Insured Loss Payee Employee As Lessor Lienholder
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. ***

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CIA CONTACT INFORMATION:

PO Box 188 Simpsonville, SC 29681
Phone: 864.688.0121 | Fax: 864.688.0138
Email: info@cossioinsurance.com

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