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Click ‘Get Form’ to open the blank COI form in the editor.
Begin by entering your name and address in the designated fields at the top of the form. Ensure that all information is accurate and clearly printed.
Next, provide the name and address of your Approved Insurance Provider (AIP). If you are an agent, include your agency name and address as well.
Indicate your role by checking the appropriate box: Agent, Adjuster, or Employee. If applicable, enter your Agent/Adjuster Code or Employee ID number.
Respond to each question regarding potential conflicts of interest by checking 'YES' or 'NO'. Refer to the reverse side for additional instructions if you answer 'YES' to any questions.
If you answered 'YES' to any questions, list those question numbers along with the corresponding Policyholder Names and Policy Numbers on the next page.
Finally, read and sign the certification statements at the bottom of the form before submitting it.
Start filling out your blank COI form online for free today!
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THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE. ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.Read more
In applications requiring more than 1 Form C contact, a multicontact relay may be used instead of 2, 3 or 4 of the standard type HG Mercury-Wetted ContactRead more
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