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Client Central

Business Clients

Request a Certificate of Insurance

To request a Certificate of Insurance...
You may call our office, send a fax, or complete the following form. If you prefer to call or fax us, you may use this form as a guide to the kinds of information we will need to process your request. To request a Certificate via this website, please complete as much of the following form as possible. When you hit the SUBMIT button, your request will be delivered via email to our customer service department for immediate attention. When handled, you will receive a copy of the Certificate by mail, unless you have given other handling instructions.

(Required *)
Insured
Today's Date: *
Date Needed: *
Requestor Name: *
Requestor Phone: *
Requestor E-Mail: *
Business Name: *
 
Holder Information (organization/person requesting Certificate from Insured)
Holder:
Address/Street:
City:
State:
Zip Code:
Attn/Contact Person: *
Phone #: *
Fax # (if fax requested):
E-Mail (if email requested):
 
Other Certificate Information
No special remarks necessary
If the Holder/requestor has provided written Certificate requirements, please send the requirements by fax to 301-417-0040 or email us at customerservice@moodyinsurance.com.
Holder requires status as either/both: Additional Insured Loss-Payee
If Additional Insured and/or Loss Payee is required, what is your relationship to the Holder?
Performing work for the Holder or client

Lease/use of premises at

Lease of equipment or other property (describe)

Finance or lease of vehicle (describe)

Other relationship (describe)
For any of the above, is there a written contract in place? Yes    No
If there is a written contract, please send a copy of the insurance provisions section by fax to 301-417-0040 or email us at customerservice@moodyinsurance.com.
 
Distribution Instructions
To Holder: Mail Orig   Fax   E-Mail

To Insured: Mail Orig   Mail Copy   Fax   E-Mail
 
Other Remarks or Special Handling Instructions
 
        


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20251 Century Blvd | Suite 425 | Germantown, MD 20874
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