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If you are a current client of Specialized Insurance Services, Inc. and need a Certificate of Insurance (COI), you may complete the web-based form below or fill out our COI Request and fax it to us at 804-934-9790. If you also require a Waiver of Subrogation as part of your COI please also fill out our Waiver of Subrogation Request. Or simply call us toll free at 866-934-9774 and we will turn around your request ASAP.



REQUEST FOR CERTIFICATE OF INSURANCE
 Directions to request certificates of Insurance (COI's)
(*required fields are noted in red):

*Insured:
  
*Phone:
  
Fax:
  

CERTIFICATE HOLDER (*required fields are noted in red):
Company Name:
  
*Contact Person:
  
Email Address:
  
*Address:
  
   
*City:
  
*State:
  
*Zip Code:
  
*Phone:
  
*Fax:
  
Additional Insured:
   Yes No
Government Clause:
   Yes No
Job Description or Contract Number:
  
   


*This document is presented in Portable Document Format (PDF) and a PDF reader is required for viewing. Download a PDF reader or learn more about PDFs.

 
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