COI Request-Online Form

If you are insured by Brotherhood Mutual,

STOP!!!

Ministries insured by Brotherhood Mutual must download the JOB_COI Request Form & email it to [email protected]

JOB_COI Request Form

For all other ministries NOT insured by Brotherhood Mutual, please complete this web form.

Note: If you have multiple COI's to request, you may wish to download our fill-able COI Request Form.

COI Request Form

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Please Note: Courter Financial Services, LLC will provide the completed COI to the Insured. The Insured is responsible for sending the completed COI to the Certificate Holder that has requested it.

CLIENT INFORMATION: Name*

Main Address*

Email Address*

Phone #*

Name of person submitting this Online COI Request*

Position held by person submitting this Online COI Request*

Date Online COI Request is being submitted*

CERTIFICATE HOLDER INFORMATION (Person requesting the COI): Name*

Address*

Date Certificate Holder has requested to receive the COI*

DESCRIPTION OF OPERATIONS: Date(s) of Operations/Activities*

Please list any and all Operations/Activities/Locations to be involved for the purposes of this Certificate*

ADDITIONAL INSUREDS (Only if the Certificate Holder has requested to be listed as an Additional Insured): Name

Name

Special Notes for Additional Insured(s):

Special Notes for Courter Financial Services, LLC?

Did you receive a written request for a Certificate of Insurance from the Certificate Holder? If yes, please email a copy to [email protected]*

YesNo

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