Certificate Request

Insured Name*

Policy Number or Binder Number*

Certificate Issue Date*

Cannot be backdated - Format - dd/mm/yyyy

Certificate Type*

Loss Payee Certificate
Certificate of Proof of Insurance
Liability Certificate
Pink Card

Loss Payee Certificate is to be given to Lenders, Mortgagees, Lien-holders, Lessors, Financing Companies. Certificate of Insurance is given to anyone who is dealing with your company and has interest in your work.

Certificate Holder Name*

This is the name of company asking you to provide certificate of insurance.

Certificate Holder Address*

This is the address of company asking the certificate, NOT your address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Certificate Holder Email

Certificate Holder Phone

Select all the risks for which Certificate is Required*

Property
General Liability
Automobile
Cargo
Umbrella
Equipment

Vehicle Details

Example:- Year, Make, Model and VIN, Purchase or Sale Date | 2018 Hino 386 1 HSG7856785GBHG986 April 20, 2019

Property Details

Example:- Address - 4112 30 St NW, Edmonton, AB, T6T 1K5, Value - Building - $ 500K and Content $300K

Equipment Details

Example:- Year - 2004, Make - BOB CAT, Model - 65R, Serial Number - 654FG32 Value - $ 58000

Reason why the Certificate is Requested

Explain your relationship with Certificate Holder

Name of Person Requesting Certificate*

First Last

Email*

Phone*

Upload all the documents related to this Certificate Request

Drop files here or

Example : Bill of Sale, Lease Agreement, Contract with Insurance Requirement etc.

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Certificate Request

The certificate/s will be processed within next business day