Request a Certificate - Casswood Insurance Agency, Ltd.

COI Request - Business Client

If you currently have an active business account with our agency you can use this form to request that a certificate of insurance be sent in your behalf to specific certificate holders for a specified purpose.

Casswood Customer Information

Please complete this information completely.

Customer Name *

Customer Code

Person completing this form? *

Your Email Address *

Your Fax Number *

Certificate Holder Information

All fields must be completed for a certificate to be issued.

Certificate Holder Name *

Attention of

Holder's Street Address *

Holder Address 2

Holder City *

Holder State *

Holder Zip (+4 if available) *

Holder's Fax for Delivery

Holder's Email for Delivery

Does Holder require they be shown as additional insured? If yes, explain below. *

Yes No

Notes:
If specific wording is required it must be reviewed with your Account Manager. Call 800-972-2242

* indicates required fields

We appreciate your using our online certificate request service. When you request a certificate online, you acknowledge that a certificate will only be issued with approval of the insurance carrier, for valid (in force) policies and does not provide additional coverage or extensions of coverage unless they are evidenced by endorsement to your insurance policy.