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

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?

Additional Insured Certificate
Certificate only (no additional insured need be added)
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

General Liability
Product Liability
Workers Compensation
Commercial Auto
Pollution Liability
Loggers Broad Form 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

Please select the type of Certificate needed*

Certificate only - no AI
Additional Insured Certificate
Not sure

Certificate holder information

Name of Certificate holder or Additional Insured*

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

Phone

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

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