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Certificate Request Form | DurAmerica Brokerage


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Let's start with some basic information.
Insured
Required
First Name
Required
Last Name
Required
E-Mail Address
Required
ZIP / Postal Code
Required
Now let's get to the details about the certificate.
Please select which insurance policies are to be listed on the Certificate of Insurance (COI).
Optional




Certificate Holder Complete Name, Address, Phone Number & Email Address
Required
Do you need to add additional insured's to this COI?
Required
If yes, how many additional insured's are required?
Optional
Additional Insured Complete Name, Address, Phone Number & Email Address
Optional
Describe the work that is being performed.
Required
Start & Finish Dates of Project
Required
Job Location
Required
We are finished! Just a few questions left.
Who would you like us to send the certificate to? (include name and email address or fax number)
Required
Upload Sample Certificate or Contract to Us
Optional
After submitting this request we will review your request as quickly as possible and contact you if any additional information is required.
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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37-14 30th Street
Long Island City, NY 11101
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