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Need An Insurance Certificate?
Please Complete The Form Below
Certificate Request
Please Complete The Form Below
Our Address
750 Terrado Plaza, Suite 238 Covina, CA 91723
lillian@bakerromero.com
(626) 332-2258
Everyday 9:00am - 6:00pm
Certificate
Type of Cerificate
New Certificate
Renewal
Revision
Certificate Requested By
Your Name
First
Last
Phone
Email
Fax
Issue Certificate To:
Certificate Holder:
Individual Other Than Holder:
Email
Phone
Fax
Address
Street Address
City
ZIP / Postal 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:
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
Specify
Additional Comments
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