Insured Solutions
Insured Solutions

Workers' Compensation Certificate of Insurance

  • Waiver of Subrogation Certificate Notices :
    - Fees vary based on carrier. Please contact your CSR for cost prior to submitting the request.
    - All Waiver of Subrogation certificates are subject to carrier approval and can take up to 3 business days to process.
  • Note: "Additional Insured" only applies to general liability insurance certificates, not workers’ compensation certificates.
Submitted By: *
Client Company Information:  
Insured Company Name: *
Company Address: *
Your Phone Number: *
Does this certificate require a
waiver of subrogation: *
Distribution: A copy should be emailed in PDF to:
A copy should be faxed to:
Certificate Holder Name: *
Certificate Holder Address: *
Special Instructions:
(Processing time may vary
for certificates requiring
special instructions)