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Proof of Insurance Information Form
Record key insurance policy details, coverage limits, and certificates in one clear form.
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Proof of Insurance Information Form Template
[Organization / Landlord / Company Requesting Proof of Insurance]
[Street Address]
[City, State/Province, ZIP/Postal Code, Country]
Phone: [Phone Number]
Email: [Email Address]
1. Form and Request Details
Form Title: Proof of Insurance Information Form
Date Completed: [MM/DD/YYYY]
Reference / File / Contract No.: [Reference Number]
Purpose of Insurance Verification:
[Purpose, e.g., rental, contract, project, event]
2. Party Providing Insurance (Insured)
Insured Name or Business Name: [Insured Name]
Contact Person (if business): [Contact Person]
Street Address: [Insured Street Address]
City, State/Province, ZIP/Postal Code, Country: [City, State/Province, ZIP/Postal Code, Country]
Phone: [Insured Phone Number]
Email: [Insured Email Address]
Tax ID / Business Registration No. (if applicable): [ID Number]
3. Insurance Provider Information
Primary Insurance Company: [Insurance Company Name]
Policy Issued Through (Agent / Broker): [Agency or Broker Name]
Agent / Broker Contact Name: [Contact Name]
Phone: [Agent / Broker Phone Number]
Email: [Agent / Broker Email Address]
Office Address: [Agency Address]
4. Policy Types and Basic Details
Select and complete each type of coverage that applies.
4.1 General Liability Insurance
☐ Not Applicable
Policy Number: [Policy Number]
Policy Type: [Occurrence / Claims-Made / Other]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
4.2 Commercial Auto / Vehicle Insurance
☐ Not Applicable
Policy Number: [Policy Number]
Covered Vehicle(s): [Vehicle Description or “Fleet”]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
4.3 Property Insurance
☐ Not Applicable
Policy Number: [Policy Number]
Insured Location or Property: [Property Description]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
4.4 Workers’ Compensation Insurance
☐ Not Applicable
Policy Number: [Policy Number]
Jurisdiction(s): [State/Province/Country]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
4.5 Professional / Errors and Omissions Liability
☐ Not Applicable
Policy Number: [Policy Number]
Covered Profession / Services: [Description]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
4.6 Other Insurance
☐ Not Applicable
Coverage Type: [Coverage Description]
Policy Number: [Policy Number]
Effective Date: [MM/DD/YYYY]
Expiration Date: [MM/DD/YYYY]
5. Coverage Limits (Summary)
Complete for each applicable policy.
General Liability – Each Occurrence Limit: [Currency and Amount]
General Liability – Aggregate Limit: [Currency and Amount]
Commercial Auto – Combined Single Limit or Per Person / Per Accident: [Currency and Amount]
Property Insurance – Limit of Insurance: [Currency and Amount]
Property Insurance – Deductible: [Currency and Amount]
Workers’ Compensation – Statutory Limits: [Yes / No]
Employers’ Liability Limits: [Currency and Amount]
Professional Liability – Each Claim Limit: [Currency and Amount]
Professional Liability – Aggregate Limit: [Currency and Amount]
Other Coverage Limits: [Description and Amounts]
6. Additional Insured, Waivers, and Special Requirements
Certificate Holder / Requesting Party Name: [Certificate Holder Name]
Certificate Holder Address: [Certificate Holder Address]
Additional Insured Status for Certificate Holder:
☐ Required and Added
☐ Required but Not Yet Confirmed
☐ Not Required
Waiver of Subrogation in Favor of Certificate Holder:
☐ Required and Added
☐ Required but Not Yet Confirmed
☐ Not Required
Primary and Noncontributory Wording:
☐ Required and Included
☐ Required but Not Yet Confirmed
☐ Not Required
Other Special Endorsements or Requirements:
[List endorsements or requirements]
7. Proof of Insurance Documents Provided
Check all that apply and attach copies where required.
☐ Certificate of Insurance (COI)
☐ Copy of Policy Declarations Page
☐ Auto Insurance ID Card
☐ Workers’ Compensation Certificate
☐ Additional Insured Endorsement
☐ Waiver of Subrogation Endorsement
☐ Other: [Document Description]
Document Reference Numbers or IDs:
[Reference Numbers]
8. Internal Review and Verification (For Requesting Party Use)
Received By: [Staff Name]
Date Received: [MM/DD/YYYY]
Initial Review Outcome:
☐ Meets minimum insurance requirements
☐ Missing documents or endorsements
☐ Coverage limits insufficient
☐ Other: [Description]
Follow-Up Required:
☐ Yes
☐ No
Details of Follow-Up or Conditions:
[Notes on required changes or additional documents]
9. Certification by Insured or Insurance Representative
I certify that the information provided in this form is accurate to the best of my knowledge and that the listed policies were in force or are expected to be in force for the coverage period stated, subject to the terms, conditions, and exclusions of each policy. This form is not a policy or a guarantee of coverage.
Name of Person Completing This Form: [Name]
Title / Role: [Title or Role]
Company (Insured or Agency): [Company Name]
Phone: [Phone Number]
Email: [Email Address]
Signature: _______________________________
Date: [MM/DD/YYYY]
10. Acknowledgment by Requesting Party (Optional)
The requesting party acknowledges receipt of this Proof of Insurance Information Form and any attached documents.
Requesting Party Representative Name: [Name]
Title / Role: [Title or Role]
Signature (if used): _______________________________
Date: [MM/DD/YYYY]
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Easy-to-understand jargon
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Details
Learn more about
Proof of Insurance Information Form
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
PROOF OF INSURANCE INFORMATION FORM TEMPLATE FAQ
What is a Proof of Insurance Information Form?
A Proof of Insurance Information Form is a document used to collect and confirm details about an individual’s or company’s insurance coverage. It records policy numbers, insurers, coverage types, limits, effective dates, and certificates provided, so the requesting party has a clear written record.
Who typically uses this form?
Landlords, property managers, vehicle rental and lease companies, contractors, clients, and event venues often use this form when they need proof that another party carries required insurance (for example, liability, auto, property, or workers’ compensation coverage).
What should be included on a proof of insurance form?
The form should list the parties’ names and contact details, type of insurance, insurer information, policy numbers, coverage limits, effective and expiration dates, any additional insured or waiver requirements, and what documents are attached (such as certificate of insurance or copy of ID card).
Is this form the same as a certificate of insurance?
No. A certificate of insurance is usually issued by the insurer or broker. This form is an internal document used to collect and summarize insurance details and confirm what proof has been provided. It can be used together with certificates and policy documents.
Can AI Lawyer help me customize this Proof of Insurance Information Form?
Yes. AI Lawyer can help you adapt this form to match your industry or compliance requirements by adding specific coverage types, minimum limits, or internal approval fields while keeping the layout simple and easy to use.
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