REQUEST CERTIFICATE

Please fill out the form below to request a Certificate of Insurance

COI REQUEST

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name of insured *

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Additional Insured Waiver of Subrogation Primary & Non-Contributory Aggregate Limits Per Project

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Statewide Insurance Services
16230 HWY 603, Suite B
Kiln, MS 39556

Mailing: PO BOX 277
Kiln, MS 39556

Phone: 228.255.1188
Fax: 228.255.5753

HOURS:
Monday - Friday 8:00 am - 4:30 pm

Please fill out the form below to request a Certificate of Insurance

COI REQUEST

​Is the certificate holder requiring any additional endorsements?

Is the certificate holder requiring any additional endorsements?