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Certificate of Insurance Request

To help you get the correct certificate as soon as possible, please complete the following form.


Before filling out this form, please have the following information available.

  • Name of certificate holder

  • Mailing address of certificate holder

  • are you required to name them as additional insured on your policy

  • If so, what is their insurable interest


Additional Insured

An additional insured is a party, typically added to an insurance policy by an endorsement, who is not the policyholder but still receives coverage under certain circumstances. This allows a party, like a client or property owner or landlord, to be protected by the named insured's policy for liabilities arising from the named insured's actions. There is a charge to name someone as additional insured.

Please refer to the policy number on your policy that was sent to you from Corinthian

Contact Information

Information for the person that we can contact regarding this certificate request if we have questions.

Certificate Holder Information

Please complete the fields below based on the exact information the certificate holder requires on the certificate. If you are unsure how to complete this section, please contact us at 508-533-5103.

Choose one
Proof of Insurance (no coverage provided to certificate holder)
Additional insured (coverage is provided for certain circumstances)

Certificate Holder Mailing Address

Mailing Address of certificate holder

For a specific event or activity, please provide event dates and details

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