Is notarization required?

Generally, standard insurance certificate requests do not require notarization. Specific endorsements or legal instruments may require notarization or RON; check contract terms and state notary rules.

Can the form be signed electronically?

Yes. Electronic signatures meeting ESIGN (15 U.S.C. ch. 96) and applicable state UETA requirements are valid for most insurance request forms, provided intent, consent, attribution, and retention criteria are met.

How do I correct an error after submission?

Ask the broker or insurer to reissue the certificate with corrected fields. Retain both versions and an audit trail showing who requested the change and why.

What authentication level is appropriate?

Email-link or SMS code authentication is typical. Use stronger methods (KBA or two-factor) when insurer verification or contractual sensitivity requires higher assurance.

How should I store issued certificates?

Store signed certificates and associated audit metadata in secure, access-controlled storage for the retention period required by contract, IRS, or industry regulation.

Who can revoke a request?

The submitting party or authorized contract signatory can withdraw a request; if a certificate has been issued, obtain a replacement certificate or written clarification from the insurer.

Electronic Signature
Templates
Insurance
Insurance Request Form

Insurance Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Request For Insurance

Federal Employees' Group Life Insurance (FEGLI) Program

SF 2822

Part A — Employing Agency

1. Employee's name (last, first, middle)

2. Date of birth

3. Social Security number

4. Employing department/agency (including bureau or division)

5. Work location (city and state)

6. Employee's daytime phone number

7. Has more than 1 year passed since the effective date of the employee's last waiver or cancellation of FEGLI coverage?

Yes No

8. Has the employee had any continuous absence of at least 3 weeks because of sickness or injury during the past year?

Yes No

9. Signature of certifying agency official

10. Date

11. Title of certifying agency official

12. Agency telephone number

13. Name and mailing address of agency (type or print)

14. Email address, if you want OFEGLI to email its decision

15. FAX number, if you want OFEGLI to fax its decision

Part B — OFEGLI

We approve this request. We deny this request.

2. OFEGLI Reviewer

3. Date

Part C — Employee

1a. Your address (number, street, city, state, ZIP code)

1b. Daytime telephone number

2. Have you had any change in health in the past 5 years?

Yes, give details No

3. Have you sought medical advice or been treated by a clinic, hospital, physician, or healer within the past 5 years?

Yes, give details No

4. Have you ever been denied life or health insurance, or offered it at higher than normal rates?

Yes, give details No

5. Have you ever had or were you ever told you had the following? Check "Yes" or "No". If "Yes", explain in 5a.

Chest pain, swollen ankles, or disease of heart or blood vessels?	Yes No
High blood pressure? How high?	Yes No
Asthma, emphysema, chronic bronchitis or other lung diseases?	Yes No
Liver conditions, ulcers, or gastrointestinal (G.I.) conditions?	Yes No
Disease of kidney, bladder, male or female organs, or albumin or sugar in the urine?	Yes No
Unconsciousness, paralysis, epilepsy, or other nervous or mental disorder?	Yes No
Cancer, tumor, polyp, or disease of the blood, spleen, or lymph glands?	Yes No
Diabetes, tuberculosis, or drug habit?	Yes No
Biopsy, surgical operation, or radiation treatment?	Yes No
Arthritis or any muscular weakness or disorder?	Yes No

5a. Briefly state condition, dates, duration, and kind of treatment. Also state names and locations of doctors and hospitals.

6. Your signature (You must sign in the presence of the examining physician).

7. Date

Part D — Examining Physician or Other Healthcare Provider

This examination is for Federal Employees' Group Life Insurance purposes. Fully complete, sign and date this part.

The employee must pay any fee for this examination. Do not perform any special examinations or incur any unusual expense.

Ask the employee to sign Item 6 in Part C in your presence.

Do NOT RETURN THIS FORM TO THE EMPLOYEE. MAIL IT TO: Office of Federal Employees' Group Life Insurance, P.O. Box 6512, Utica, NY 13504-6512

1. Print employee's full name (last, first, middle)

2. Gender

Male Female

3. Date of birth

4. Height

5. Blood pressure

6. Pulse (at rest)

7. Weight

8. Does examination reveal abnormality of:

General movements, strength, stamina, responsiveness, coordination, etc.?	Yes No
Eyes, ears, nose, throat?	Yes No
Nervous systems and reflexes?	Yes No
Respiratory system?	Yes No
Skin and glands?	Yes No
G.U. system?	Yes No
Heart, arteries, or veins?	Yes No
Any murmurs present?	Yes No
Extremities and skeletal or muscular system?	Yes No

9. Fully describe abnormalities.

10. I certify that the employee signed Part C in my presence; that I have carefully examined the employee; and that I correctly recorded my complete findings.

Signature of examining physician or other healthcare provider

Date of examination

11. Name and address of examining physician or other healthcare provider

Telephone number

What the Insurance Request Form Is and when it’s used

An Insurance Request Form is a standardized document used to request proof of insurance, certificates of insurance, policy endorsements, or coverage details from an insured party or insurer. Typical users include risk managers, procurement teams, brokers, contractors, and certificate holders who need verified policy information such as policy numbers, effective and expiration dates, limits of liability, and named insured fields. The form supports accurate verification for contracts, permits, and vendor onboarding and is often submitted electronically or with an eSignature to accelerate processing and preserve an audit trail.

Why a clear Insurance Request Form matters

A well-structured Insurance Request Form reduces ambiguity, shortens verification cycles, and protects contractual parties by documenting required coverage and certificate details. Clear fields and instructions reduce delays, lower the risk of claims disputes, and create a reproducible record that supports compliance and auditability.

Who completes and relies on an Insurance Request Form

Risk, procurement, and compliance teams typically initiate requests; brokers and insured parties complete them. Use depends on the transaction and contractual requirements.

Risk managers and corporate compliance teams who verify vendor insurance and contractual coverage details.
Insurance brokers and agents who prepare certificates and endorsements for clients and third parties.
Vendors, contractors, and certificate holders needing proof of insurance to satisfy contracts or permits.

Knowing the audience helps you include only relevant fields and reduces the need for follow-up clarification from insurers or certificate holders.

Step-by-step process to complete and submit the form

Follow a consistent order: collect insured details, confirm coverage, request certificate, and retain proof. This reduces rework and ensures a complete record.

01

Collect Details: Gather legal name, policy number, and contact information.
02

Confirm Coverage: Verify coverage types and limits with the insurer or broker.
03

Request Certificate: Ask the insurer or broker to issue the COI and any necessary endorsements.
04

Archive Proof: Store the certificate and audit trail for the document retention period.

How to configure an online Insurance Request workflow

Set up fields, routing, and authentication to match your internal approval and compliance requirements before sending the request.

Field	Configuration
Required Fields	Insured name \| policy number \| certificate holder
Routing Rules	Send to broker for completion, then to risk manager for approval
Authentication	Email link or SMS code; KBA optional for high-risk requests
Retention Settings	Enable audit trail and secure storage for regulatory retention

Typical submission and verification flow

A concise, repeatable flow reduces handoffs and speeds certificate delivery. Automate steps where possible to capture audit metadata.

Initiate Request: Requester fills form and submits to broker or insurer.
Broker/Insurer Review: Agent verifies policy and prepares certificate.
Issue Certificate: COI and endorsements generated and delivered to certificate holder.
Archive Record: Signed certificate and audit trail stored electronically.

Platform considerations for eSubmission and eSignature

Choose a platform that supports secure uploads, audit trails, and the authentication level your organization requires.

File Formats: PDF and DOCX are standard for certificate templates.
Integrations: CRM and storage integrations reduce manual entry.
Authentication: Email, SMS, or stronger methods available

Ensure the platform can preserve signatures and metadata in an auditable format and supports your retention policy and industry compliance needs.

Essential elements to include in a professional form

A complete Insurance Request Form balances brevity with the necessary legal and identification details to prevent follow-up and support verification.

Identifying Data

Full legal name, DBA if applicable, and taxpayer identification where relevant help insurers locate the exact policy without ambiguity and speed certificate issuance.

Policy Identifiers

Policy number, insurer name, and producer contact let recipients confirm coverage directly with the insurer or underwriter when verification is required.

Coverage Details

Types of coverage requested, limits per occurrence and aggregate, and any sublimits must be explicit to ensure the certificate meets contract requirements.

Effective Dates

Clear effective and expiration dates determine whether the requested coverage aligns with contract timing and prevent gaps in coverage.

Certificate Holders

Designate the entity to receive the COI and include the full legal name and address to avoid misdirected certificates or invalid delivery.

Additional Clauses

Endorsements, waiver of subrogation, or primary/ non-contributory language should be stated explicitly to ensure insurer recognition and proper endorsement.

Security and compliance elements to capture

Encryption: TLS 1.2/1.3

Data at Rest: AES-256 encryption

Audit Trail: IP and timestamps

Access Controls: Role-based permissions

HIPAA Readiness: BAA option available

Standards: SOC 2 and ISO 27001

Common errors to avoid when preparing a request

Submitting an incomplete insured name or alias leads to insurer delays or misissued certificates and additional follow-up communication.
Providing inaccurate policy numbers or insurer contact information prevents direct verification and lengthens processing time for certificate issuance.
Requesting ambiguous coverage language or unspecified limits causes insurers to decline endorsement or issue non-compliant certificates.
Failing to specify certificate holder contact details or the required endorsements can result in rejected or non-actionable certificates.

Consequences of incorrect or missing information

Coverage Denial: Claims may be denied for inadequate or missing coverage.

Contract Breach: Noncompliance can trigger contractual penalties or termination.

Financial Exposure: Uninsured losses shift to the requesting party.

Operational Delays: Project start dates or permits may be held.

Regulatory Risk: Industry rules may impose fines or sanctions.

Tax Impacts: Backup withholding triggers with incorrect TINs

Typical timelines and processing expectations

Processing times vary by insurer and broker workload; provide realistic expectations to stakeholders and allow buffer for endorsements or corrections.

Acknowledgement Time:

Insurer or broker usually acknowledges receipt within 1–3 business days.

Certificate Issuance:

COI and simple endorsements commonly issued within 1–5 business days.

Complex Endorsements:

Custom endorsements or insurer approvals can take 7–14 business days.

Claim Reporting:

Report potential claims per policy terms, often within 30 days of discovery.

Retention Period:

Maintain issued certificates per record retention rules and contract requirements.

Real-world examples of using e-submitted insurance requests

Organizations use electronic requests to speed verification, reduce paper, and centralize records across teams and vendors.

Fertility Centers of Illinois

A healthcare provider centralized certificate requests to streamline vendor onboarding and reduce paper handling.

The team automated request routing to its insurance broker.
"The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Martin Properties

A regional real estate operator standardized COI requirements across properties to avoid liability gaps.

Property managers now submit uniform requests before contractor access.
"I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently."

eSignature vendor comparison for Insurance Request Form workflows

Compare common vendor features and pricing models relevant to certificate and endorsement workflows. signNow is shown first per comparison standards.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions about completing and submitting the form

Answers address common legal, technical, and operational concerns when requesting insurance documentation electronically.

Need help? Contact support

Is notarization required?
Generally, standard insurance certificate requests do not require notarization. Specific endorsements or legal instruments may require notarization or RON; check contract terms and state notary rules.
Can the form be signed electronically?
Yes. Electronic signatures meeting ESIGN (15 U.S.C. ch. 96) and applicable state UETA requirements are valid for most insurance request forms, provided intent, consent, attribution, and retention criteria are met.
How do I correct an error after submission?
Ask the broker or insurer to reissue the certificate with corrected fields. Retain both versions and an audit trail showing who requested the change and why.
What authentication level is appropriate?
Email-link or SMS code authentication is typical. Use stronger methods (KBA or two-factor) when insurer verification or contractual sensitivity requires higher assurance.
How should I store issued certificates?
Store signed certificates and associated audit metadata in secure, access-controlled storage for the retention period required by contract, IRS, or industry regulation.
Who can revoke a request?
The submitting party or authorized contract signatory can withdraw a request; if a certificate has been issued, obtain a replacement certificate or written clarification from the insurer.

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