Insurance Certificate Information Submittal

Submit insurance information for CT & PCO
This certificate is issued as a matter of information only and confers no rights upon the certificate holder.
This certificate does not amend, extend or alter the coverage afforded by the policies below.

Insured Name:*

PVL License Type:*

PVL License Number (e.g. 54321 - Do not include License Prefix):*

Transaction Type:*

Insurance Type:*

Insurer Affording Coverage:*

Upload a Copy of the Certificate:*

Additional Comments (optional):

As the authorized representative, I certify that the policy of insurance submitted has been issued to the insured named above for the policy period indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which the submitted certificate may be issued or may pertain, the issuance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policies. Aggregate limits submitted may have been reduced by paid claims.

Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to submit within 30 days notice to the certificate holder, but failure to do so shall impose no obligation or liability of any kind upon the insurer, it’s agents or representatives.

Authorize Representative:*

First Middle Last

Contact Email:*