Request Workers Comp Certificate Certificate Request Form Twitter Client Company Information (* = Required Field). Company Name * Email Address * Requested By * Date Requested * Certificate Holder Information (Required for Certificate to be issued) Holder Name Address * City * State * Zip Please Send the following Documents: Waiver of Subrogation Endorsements (Check all that apply) Please Note: Once submitted, please wait a few seconds for a confirmation. If you do not receive a confirmation, we did not receive your request. PLEASE ALLOW 24HRS TO PROCESS YOUR REQUEST