Total: ...

Certificate of Insurance & Additional Insured Endorsement

Requet a Certificate of Insurance/ Additional Insured Endorsement Request! Please complete the form below and an underwriter will be in contact shortly. You can also reach out to the numbers below for any questions or concerns.

Phone: 1-800-874-9191 | Alt Fax: 602-992-8932 | E-Fax: 480-452-0593

Customer Account Number

AFIG Customer number if known

Named Insured

Insured Name on policy

Please Select From List:

Policy Number

Certificate Information

Event Acticvity Reference

Event/Activity Date(s)

Enter dates of activity that certificate pertains to

Event / Activity Website (if any)

Use format http://www.xyzcompany.com

Contact Name

Email Address

Contact email address

Contact Phone Number

Please Select:

Certificate Holder Name

Name of Certificate Holder / Premises Owner

Certificate Holder Address

Mailing Address of Certificate Holder

Comments or special instructions

I/We hereby make reqiest for activity or event shown above. I/We understand and agree that this request shall form part of any policy issued or in effect and that the Company requires that I/We obtain certificates of insurance from independent contractors.

I/We agree that, if this application is sent to you by facsimile or other electronic means, you may act upon it whether or not you receive an original hard copy. Coverage is not provided for events, activities or show dates that have not been declared and approved by the insurance company in writing prior to of the event.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

Authorized Applicant

Name of authorized applicant

For Immediate Assistance Call Toll Free 1-800-874-9191

Verification