If you would like to request a certificate of insurance, please provide the following information, then click the "send form" button below. PLEASE NOTE: If the policyholder is a TEMPORARY STAFFING OR LEASING/PEO COMPANY, please call the Underwriting Department at (405) 232-7663 ext. 5107 or 1-800-347-3863 ext. 5107 to request a certificate instead of using this form. *denotes a required field. *Is policyholder a temporary staffing or leasing/PEO company?   yes no Policyholder Name: Policy Number (8 digits): Certificate Holder Name: Address: City: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OKOR PA PR RI SC SD TN TX UT VA VT WA WI WV WY        Zip:   Type of work to be performed: Does the certificate holder require: > an alternate employer endorsement: Yes No > a waiver of subrogation: Yes No Other specific instructions: *Your Name: *Your Phone Number: Your E-mail Address: If more information is needed, a service representative will contact you. Otherwise, the certificate will be issued as soon as possible. Please click only once to avoid transaction duplication.     back to top