Certificate of Insurance Request Form

Please allow 48 hours for a response. If a rush certificate is needed, please call Kin Ong at (916) 927-7727 or (800) 400-2642.

TO:   Kin Ong, PARSAC
FROM:  
Entity:  

CERTIFICATE HOLDER:


PLEASE CHECK APPROPRIATELY:

Coverage: Liability
Evidence of Insurance Only
Additional Insured Endorsement *
Coverage: Workers' Compensation
Loss Payee Endorsement (Property) *

* If the Certificate Holder is requesting to be added as an Additional Insured or Loss Payee, a complete copy of the contract, agreement or lease must be provided.

LIMITS REQUESTED:
LIABILITY SIR:
WORKERS COMP SIR:
DATES OF ACTIVITY:
DESCRIBE LOCATION AND TYPE OF ACTIVITY OR LEASE:
UPLOAD A COPY OF THE CONTRACT (.pdf, .txt or .doc only):
SEND MY CERTIFICATE BY:



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