Certificate Request

Use this form if you are our client or a third party requesting a Certificate of Insurance.

Submission of this form does not automatically change the policy. The coverage will not change until this request is received and confirmed by TPS Insurance.

Your Name * First Last
Company Name (Named Insured) *

Enter your business name if a TPS client or our insured's company name if you a third party.
Name of the Certificate Holder *

The company that is requesting the certificate of insurance.
Address of Certificate Holder
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email *
Fax Number - (###) - ### ####
Holder is listed as: (select all that apply) Additional Insured Loss Payee
You may select more than one choice.
Where should we send the Certificate? * Directly to the Holder Directly to You Both
If you choose 'Both' enter in the email address or fax number of other party.
If 'Both' enter in fax number or email address to send to other party.
How should we send the Certificate? * Email Fax Mail
Reason for Certificate and other special comments/requests.