Party Rentals Indoor Inflatables Broker With Us




     

     

    Certificate Request Form

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

    *** 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. ***

    1) What Type of Certificate do you Need?


  •  

  • 2) About Your Company


    Your Customer ID Number:
  • If you are not seeing the correct information please double-check that you have entered the correct Customer ID #.

  • Contact Name:

  • Your Company Name

  • Contact Phone Number

  • Your Email



  • 3) Additional Insured Information

    Please verify that you are using the correct information with the certificate holder before requesting certificate! Entering the incorrect information will cause a delay in processing, because the information will need to be revised.


    Relationship

    Name of Certificate Holder

    Their Mailing Address

    City State Zip
    Additional Insured Email




    4) Event Date and Location


    Start Date (mm/dd/yyyy)

    End Date (xx/xx/xxxx)


    Event Location: Street
    City State Zip


    Additional Information (OPTIONAL)


    This is OPTIONAL if you do not need special wording or have no attachments please leave these fields blank.

    Special Wording

    Attachments