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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
  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:




© 2009 CRMA - California Risk Management Authority. All Rights Reserved.
1430 W Herndon Ave. Fresno, CA 93711
559-476-2999 - FAX 559-476-2933