A Certificate of Insurance is a form that provides evidence to someone else that you or your business has insurance coverage in force. It shows the company that insures you, the policy number, the type of coverage, the amounts of coverage, and the policy effective and expiration dates.

If you need to provide a certificate to someone to show evidence of your business’s insurance, following is the information we normally need in order to process your request.

Get a Certificate

  2. You may call this information in to us, or fax it or email it.

  3. Your Name
    Please type your full name.
  4. The Name of your business
    Invalid Input
  5. Your phone number
    Please provide your phone number.
  6. Your fax number
    Invalid Input
  7. Your email address
    Please type your valid email address.
  8. What insurance coverage is the certificate for
    Please tell us for which insurance policy you need a certificate.
  9. Who is requesting the certificate?

  10. If the person requesting the certificate has given you a document that specifies what they are looking for in your certificate you may fax that to us or email it.

  11. Their name
    Invalid Input
  12. The name of their business (if any)
    Invalid Input
  13. Their mailing address
    Invalid Input
  14. Their phone number
    Invalid Input
  15. Their fax number
    Invalid Input
  16. Their Email Address
    Invalid Input
  17. Are they asking to be named as additional insured?
    Invalid Input
  18. There may be a charge for adding an additional insured.
  19. Any other special provisions requested? If the certificate is for a specific event, project, location, or dates, please explain
    Please type a message.
  20. Re-type the security field numbers you see in the box.
  21. Security Field
    Security Field
    Invalid Input
  22. To keep a copy of this form, please Print before Submitting

Network with BTIA

Follow us on Twitter & Facebook:
BTIA on Facebook  BTIA on Twitter
Share this page with your network:
AddThis Social Bookmark Button


If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.