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Certificate Request

Please Complete The Form Below

""
1
Type of Certificatepick one!
Your Contact Information
Certificate Requested By
Your Nameyour full name
Phone
Fax
Issue Certificate To
Certificate Holder
Individual Other Than Holder
Phone
Fax
Address
City
Zip Code
Specific Contact Requirements
Job Name / or Name of Event
What is the purpose of the certifiicate?Insurable interest(i.e. special event, funder, landlord)
If certificate is for a special event, please provide the date:
Describe type of event:
Location of Event
Estimated number of attendees:
Will Alcohol be served:
Will Alcohol be sold:
Anticipated Gross Revenue from Event:
Provide Specific Requirements and/or Special Wording
Will endorsement be required with certificate?if yes, please provide a copy of contract:
Attach a document:(i.e. contract, lease, special event flyer)
Upload
Provide Specific Requirement
Include The Following
Other
Include The Waiver of Subrogation Endorsement On
If applicable
Other
Our Delivery Options
Certificates will be issued after the request has been received and reviewed. Our certificates department will contact you if any additional forms or information are required prior to approval by the insurance carrier.
Certificates should be sent to
Other
Additional Comments
Commentsmore details
0 /
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""
1
Type of Certificatepick one!
Your Contact Information
Certificate Requested By
Your Nameyour full name
Phone
Fax
Issue Certificate To
Certificate Holder
Individual Other Than Holder
Phone
Fax
Address
City
Zip Code
Specific Contact Requirements
Job Name / or Name of Event
What is the purpose of the certifiicate?Insurable interest(i.e. special event, funder, landlord)
If certificate is for a special event, please provide the date:
Describe type of event:
Location of Event
Estimated number of attendees:
Will Alcohol be served:
Will Alcohol be sold:
Anticipated Gross Revenue from Event:
Provide Specific Requirements and/or Special Wording
Will endorsement be required with certificate?if yes, please provide a copy of contract:
Attach a document:(i.e. contract, lease, special event flyer)
Upload
Provide Specific Requirement
Include The Following
Other
Include The Waiver of Subrogation Endorsement On
If applicable
Other
Our Delivery Options
Certificates will be issued after the request has been received and reviewed. Our certificates department will contact you if any additional forms or information are required prior to approval by the insurance carrier.
Certificates should be sent to
Other
Additional Comments
Commentsmore details
0 /
Previous
Next
FormCraft - WordPress form builder

Our Address

750 Terrado Plaza, Suite 238 Covina, CA 91723
lillian@bakerromero.com
(626) 332-2258
Everyday 9:00am - 6:00pm