AI Requests

Please check all boxes for which either an "Additional Insured" certificate is required or just a Certificate is required

It is upon you to know weather you need an Additional Insured Certificate or just a Certificate. We strongly urge you to use "best practices" when requesting any certificate. For assistance call (209) 223-1870

File upload for indemnity requirements .pdf file format preferred

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 2.

You may upload your "indemnity" portion of your certificate requirement here. Please allow up to 48 hours for review. If this is an emergency please call us at 209 223-1870. You may also fax the indemnity agreement to (209) 223-3227.

What "type" of insurance certificate are you requesting?

Designated Insured Endorsement / Certificate Included. This is a NICO specific Certificate and endorsement and NOT an Additional Insured Certificate
Additional Insured Certificate (may include a cost. Check with your Broker/Agent)
Certificate only (Not a cost item. This is NOT an Additional Insured Certificate nor does it include any endorsemnt.
I have not a clue please help me

USE THIS FORM "ONE" PER REQUEST

If you need multiple please complete it multiple times.

check all that apply

Commercial Auto / Transportation
General Liability
Loggers Broad Form Liability
Product Liability
Workers Compensation
Pollution Liability
Farm General Liability
Lessors Risk

Name of Person making this request*

Email*

Enter Email Confirm Email

Business Name*

Our Insured's name first and last

First Last

Details if a construction job. Start date, type of work performed and project cost

Certificate holder information

Name of Certificate holder or Additional Insured*

Email of Entity requesting the Certificate

Address*

Street Address City State / Province / Region ZIP / Postal Code

Project name

in a few words summarize the project

Would you like to attach any documents?

Yes
No

File

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Name

This field is for validation purposes and should be left unchanged.

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Additional Insured Certificate or Certificate Requests

Certificate Request

Please check all boxes for which either an "Additional Insured" certificate is required or just a Certificate is required

USE THIS FORM "ONE" PER REQUEST

Certificate holder information