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Certificate of Insurance Request Form

CRMA - California Risk Management Authority

Certificate of Insurance Request Form

1430 W Herndon Ave.
Fresno, CA. 93711
559-476-2999

Attn: Lisa Perez

Email - lperez@crma-jpa.org
OR
559-476-2933 fax
 
Request for Certificate of Insurance Checklist

Request for Certificate of Insurance Checklist iconRequest for Certificate of Insurance Checklisttitle

  1. Name, mailing address, contact name of certificate holder (party requesting proof of insurance
  2. Copy of contract/agreement stating insurance requirements from certificate holder
    (If this information is not on contract/agreement please request a copy in writing)
  3. Date of event
  4. Description of event (include organization/school participating in event)
  5. A two-week advance notice would be appreciated to process the paperwork.
 
No Certificate of Insurance and/or Additional Insured Endorsement will be issued until all the above information is received in our office.
 
Date:
District Name:
Email:

**CERTIFICATE HOLDER INFORMATION**

Who:
What:
Where:
When:
 
Mailing Address:
City:
State:
   Zip:
 
Coverages: Property & Liability
Workers' Comp
Waiver of Subrogation Wording Required
Certificate Needed By:

PLEASE PROVIDE
COPIES OF INSURANCE REQUIREMENTS, SPECIAL FORMS,
SAMPLE CERTS, AND ANY SPECIAL WORDING.

Additional Info:
Special Instructions:


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