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: 2 GB, 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.

Comments

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

California Farm Insurance

Loggers Broad Form Insurance

Quote CBD, Hemp & Marijuana

Wildfire Insurance in California

Contractor Insurance General Liability