Certificate of Insurance Request Certificate of Insurance Request Date please format as: mm/dd/yyyyPlease select Auto Workers Comp General Liability Umbrella Other Please check those that apply Written Contract No Written Contract Current Policy Term Prior Term By (Requested)*From (Business Name)*Email* Phone*Prepare a Certificate of Insurance to the followingNameAddressSpecial ConditionsAdditional Insured (if required)Provide Project Specifications, Contractual Insurance Requirements and Example Certificates if available. Return to:Please enter email, fax number or mailing address of recipientPlease send me a copy of the Certificate: No Yes Certificate will be mailed, faxed or emailed per your request.NOTE: Certificates for Workers Compensation policies written through the MA Workers Compensation Risk Plan must be issued directly by the insurance company wiriting the policy. Rogers & Gray will order the certificate which will be issed by the carrier within two (2) business days. A copy will be kept on file for the insured unless instructed otherwise. Certificate will be available within 24 hours.