Photo of business man on phone

Certificate of Insurance

Request a Certificate of Insurance

To request a certificate of insurance for your account, please submit the form below. Please note that some coverages, endorsements or additional wording may be subject to review and additional premium charges.

All fields marked with an asterisk(*) are required.

    Certificate Request Form

    Our Client Name/Insured*

    Client Email*

    Person Submitting Request*

    Certificate Holder Information

    Certificate Holder Name*




    ZIP Code*

    Email Address*

    Items Required by Contract With Certificate Holder

    Please note - these items may require an additional premium charge

    1. Additional Insured


    2. If Yes to #1, is Additional Insured Endorsement Required by Written Contract?


    3. Waiver of Subrogation


    Additional Wording and Instructions

    Please avoid entering any Nonpublic Information (NPI) into this field. (Ex. Tax information, license information, policy number, date of birth, etc.)
    By submitting this form, you consent to Clark Insurance collecting your information in accordance with our privacy policy.

    Request a Free Insurance Quote