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Certificate of Insurance (COI) Request
Certificate of Insurance (COI) Request
Certificate of Insurance (COI) Request
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Please note fields with the asterisk character * in red to the right of each title are required.
General Information
Insured/Business Name
*
Requested By
*
Phone Number
*
Email Address
*
Policy Information
Policy Number
Agent Name
Certificate Holder / Additional Insured Info
Please add Certificate Holder / Additional Insured in fields below.
Name
Address
City
State
Phone
Email
Attention
Need By Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2023
2024
2025
2026
Certificate of Insurance Requirements
I. Types of Insurance Needed on Certificate:
*
General Liability
Auto Liability
Work Comp
Umbrella/Excess
Inland Marine
Auto Physical Damage
Property Bldg: BPP (Business Personal Property)
Professional Liability
Unsure
Specify
Specify the type of insurance needed on certificate
II. Type of Additional Insured:
Owner, Lessors, or Contractors
Manager or Lessor of Premises
State or Political Sub-Permits (Premises)
State or Political Subdivision
Mortgagee, Assignee, or Receiver
Vendors
Proof of Insurance Only
Owner of Other Interests – Land
Lessor of Leased Equipment
Engineers, Architects or Surveyors
Loss Payee
Dept. of Navy
DCCA – Contractors License Board
Other
If other, please describe the type of additional insured
III. Property/Inland Marine/Auto PD
Loss Payee
Mortgagee
IV. Amendments
Primary/Excess and Noncontributory
Waiver of Subrogation
Reduction in coverage or material change
V. Cancellation
10 days
30 days
Except 10 days for Work Comp
Other
If other, please describe
Description of Operations/Locations/Vehicles/Projects
How would you like your Certificate of Insurance delivered?
*
Mail
eMail
Pick Up
Fax
Mail
Address
City
State
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
eMail
Pick Up
Honolulu Office
Honolulu Office @ Harbor Court
Kapolei Office
Maui Office
Kauai Office
Kauai Office @ Kukui Grove Shopping Center
Hilo Office
Please select the office you'd like to pick it up.
Fax
File Upload
Please upload copy of contract, user agreement, or any related document needed for the certificate.
Files must be less than
8 MB
.
Allowed file types:
gif jpg jpeg png bmp tif pdf doc docx
.
Additional Comments
Additional Comments or Instructions:
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