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Insurance Brokers, Inc.

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Need An Insurance Certificate?

Please Complete The Form Below

Certificate Request

Please Complete The Form Below

Certificate

Type of Cerificate

New Certificate

Renewal

Revision

Certificate Requested By (Name of Organization)

Your Name

FirstLast

Phone

Email

Fax

Issue Certificate To:

Certificate Holder:

Individual Other Than Holder:

Email

Phone

Fax

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:

MM slash DD slash YYYY

Describe type of event:

Location of Event:

Estimated number of attendees:

Will Alcohol be served:

Yes

No

Will Alcohol be sold:

Yes

No

Anticipated Gross Revenue from Event:

Provide Specific Requirements and/or Special Wording

Will endorsement be required with certificate?

Yes

No

Attach a document:

Max. file size: 8 MB.

Provide Specific Requirement

Include the following:

General Liability

Auto Liability

Workers' Compensation

Professional Liability

Excess Liability/Umbrella

Property

Other

Please explain

Include The Waiver of Subrogation Endorsement On

If applicable:

General Liability

Auto Liability

Workers' Compensation

Other

Please explain

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:

Certificate Holder and You

Your Firm Only

Other

Address

Street AddressCityZIP / Postal Code

Specify

Additional Comments

Δ

Our Address

14752 Beach Blvd Suite 143, La Mirada CA 90638
Mailing address: P O Box 736, La Mirada CA 90637

lillian@bakerromero.com

(626) 332-2258

Everyday 9:00am - 6:00pm

Baker Romero & Associates

Copyright © 2024 Baker, Romero & Associates , All Rights Reserved Designed by AbleSource Digital

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NEW OFFICE DIRECTION:

14752 Beach Blvd., Suite 143

La Mirada CA 90638

MAILING ADDRESS:

P O Box 736, La Mirada CA 90637