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Create a New Certificate of Insurance
This certificate request page will allow you to do multiple requests without having to type in the same information each time. Please fill in the form below to request a certificate.
Insurance Agents may NOT alter Certificates of Insurance

Read more about this important issue and how it affects you.

Memo from JSA on Certificates of Insurance
Memo from NCDOI concerning Certificates of Insurance

Certificate Information
Policy Number(s):
(separate multiple policies with a comma)
Insured Name:
Holder Name:
Holder Attention (optional, e.g. ATTN: John Doe): 
Holder Street:
Please Enter ZIP Code:
Holder City, State and ZIP:
(for other countries, please contact us)
  (City and State are derived from the zip code)
Please specify any special wording needed :
Leave empty if none
Requesting special wording requires this certificate to be submitted for review.
Does the certificate holder need to hold a special status?
Please note that all companies charge an additional premium for adding additional insureds.
Requesting an additional insured requires this certificate to be submitted for review.
A designated insured is a listed name on the policy, but does not afford any extra coverages to the designated insured.

Since you selected additional insured, please provide details of the job our insured will be doing for the requested additional insured.
Notes for JSA Support Staff:
This will not appear on the certificate.
Sending notes to our support staff requires this certificate to be submitted for review.
Agency Information
Agent Name:
Agent E-Mail:
Agency Fax Number:

† Please note that all certificates must be produced by JSA. Agents do not have authority to issue certificates on our behalf.

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This program is only available to properly licensed retail insurance offices
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