Certificate of Insurance Request Motor Carrier – Insured Name of Motor Carrier ( Trucking Co.) USDOT of Motor Carrier Certificate Holder Company Name USDOT ( If a Freight Broker) Street Address ( Include Suite, Unit #, Etc) City State Zip ‘Additional Insured’ Required? YesNo Note: Some Insurance Companies may apply a fee to endorse Certificate Holder as an Additional Insured. Anything else you want to add to your request? YesNo Please describe Additional Information needed on Certificate Contact Information
