To access this form, the user must click the Select button beneath the associated image as shown below..
All starred (*) fields are required.
Defaults to your first and last name.
Requester’s Email cc:
If you would like to receive a copy of the certificate, please enter your email in the field.
Select your location from the drop down menu.
Select your department from the drop down menu.
Date Certificate needed (mm/dd/yyyy):
Click on the date box and select the date the certificate is needed.
Certificate Holder Information
Complete Certificate Holder information sections. All starred* fields are required.
Send a copy to certificate holder:
If you select yes to this statement, then the certificate will be sent to the email address entered under the ‘Certificate Holder Contact Email:’ field. If you want to send additional copies of the certificate by email or fax, enter the contact info accordingly under the respective fields ‘Send a copy of the certificate to the following email(s) or Send a copy of the certificate to the following fax(es): .A certificate holder could be a person or entity who needs evidence of coverage.
Contract Expiration (mm/dd/yyyy):
Enter contract expiration date, mirroring the requested format.
Certificate Expiration (mm/dd/yyyy):
An autofill of the Certificate Expiration date field, in all certificate request forms, has been applied. The date will automatically be set to 7/1 of current calendar year if request is submitted prior to that date. If request date is after 7/1 of current calendar year then the autofill will set to 7/1 of next calendar year. The ability to edit the filed will remain in place should the user need to change date. However, it will not allow a user to exceed the default date set.
Renew this certificate?
Select whether or not you want the certificate to renew.
Workers’ Compensation Information
Complete Workers’ Compensation information sections. All starred* fields are required.
Attach Files and Submit