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Please complete this form to request a Certificate of Insurance or an Additional Insured Endorsement.  All requests for any endorsement are always subject to approval by the carrier, and most are subject to additional charges by the insurance carrier. 

Insured/Policy Information

Insured Policy No.

Insured name       

Worker's Compensation  
Auto Liability  
General Liability  
Other

Choose one of the following options:
Additional Insured Request
Evidence Only Request

Choose one of the following options:
10 days notice of cancellation for non-payment of premium
 30 Day Notice for Cancellation Clause

Primary Wording required?   
Waiver of Subrogation required?

If any of the above information is not known, please send e-mail to pmcraig@onstads.com or fax to 925-866-2050         
 

Certificate Information

Describe the Relationship of the party who wants the Certificate to you, our insured (Project Owners, Property Owner,
General Contractor, etc)

Enter Job Reference, Location or Number

Enter the Certificate Holder Name

Enter Certificate Holder Address

Enter Certificate Holder
  Phone number 		  Fax number


Is the certificate holder to be listed as additional insured?
    If No, please complete box below

Enter Name of entity requesting to be added as additional Insured
Enter Additional Insured Address

Explain type of work to be done by the insured for the Certificate Holder (include project cost and duration)

Will the named insured or additional insured be involved in any
  (A) Ground Up Construction or
  (B) Any repair work of any of the following

Tract Home  
Condos  
Row House  
Townhomes   

 

Special Instructions

Comments:

Special Instructions can be e-mailed to pmcraig@onstads.com or faxed to 925-866-2050
 

Name of Person Completing Form: 

E-mail Address:                           

Phone No.                                   

Date Requested                            -- mm/dd/yy
 

 Please Note: All Requests are subject to approval by the carrier.
Most endorsements require an additional premium to be paid. 
  I understand that this request is for information purposes only and does not infer or guarantee that a Certificate of Insurance or Additional Insured Endorsement will be issued by the insurance carrier.  The requestor also understands and hereby agrees to pay for any and all charges incurred by the filing of those documents.  If you would like to know the cost, please contact Paula Craig at pmcraig@onstads.com or 925.242.7797.
           

 
Onstad's Insurance Agency
e-mail:  info@onstads.com
2266 Camino Ramon • San Ramon, CA  94583
(925) 866-1444 (p)
(925) 866-1560 (f)

California License No. 0383047 


 

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