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FROM: San Diego County and CERTIFICATE OF INSURANCE REQUEST TO: McGriff Insurance Services Attention: Sharon Robbins Imperial County Schools JPA Direct Line: 619-525-2836 Member/District: ______________________________ Email: [email protected] Fax: 888-328-1310 IMPORTANT! PLEASE SEND INSURANCE REQUIREMENTS YOU HAVE RECEIVED FROM THE ENTITY REQUESTING THE CERTIFICATE IN ORDER TO PROCESS THE CERTIFICATE. A COPY OF THE LEASE AND OR CONTRACT IS NECESSARY TO COMPLY WITH ANY “ADDITIONAL REQUIREMENTS” BELOW. TODAY’S DATE: DATE NEEDED: RUSH COVERAGE REQUESTED (Check all that apply): General Liability Automobile Liability Workers Compensation Equipment/Inland Marine (copies, etc.) Property Type of event: Special Instructions: DATES OF EVENT From: To: Additional Requirements (When Required by Written Contract) Certificate Revision General Liability Waiver of Subrogation (Please Note What Revisions Need To Be Made) Automobile Liability Waiver of Subrogation General Liability Additional Insured Workers Compensation Waiver of Subrogation Primary and Non-Contributory Wording CERTIFICATE HOLDER Name: Additional Insured(s) other than Cert Holder Attention: and their interest: Address: JOB INFORMATION (All operations certificates are not advisable) In order to limit the scope of coverage provided to the parties above, please provide the following information, if applicable: Job Number: Contract Name: Job Name: Contract Number: Job Description: Phase Number: Contracting Parties: Job Location:

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Page 1: Insurance Certificate Request · (Please Note What Revisions Need To Be Made) Automobile Liability Waiver of Subrogation General Liability Additional Insured Workers Compensation

FROM: San Diego County and

CERTIFICATE OF INSURANCE REQUEST

TO: McGriff Insurance Services Attention: Sharon Robbins Imperial County Schools JPA Direct Line: 619-525-2836

Member/District: ______________________________ Email: [email protected] Fax: 888-328-1310

IMPORTANT! PLEASE SEND INSURANCE REQUIREMENTS YOU HAVE RECEIVED FROM THE ENTITY REQUESTING THE CERTIFICATE IN ORDER TO PROCESS THE CERTIFICATE. A COPY OF THE LEASE AND OR CONTRACT IS NECESSARY TO COMPLY WITH ANY “ADDITIONAL REQUIREMENTS” BELOW.

TODAY’S DATE: DATE NEEDED: RUSH

COVERAGE REQUESTED (Check all that apply):

General Liability Automobile Liability Workers Compensation Equipment/Inland Marine (copies, etc.) Property

Type of event: Special Instructions:

DATES OF EVENT From: To:

Additional Requirements (When Required by Written Contract)

Certificate Revision General Liability Waiver of Subrogation (Please Note What Revisions Need To Be Made) Automobile Liability Waiver of Subrogation General Liability Additional Insured Workers Compensation Waiver of Subrogation Primary and Non-Contributory Wording

CERTIFICATE HOLDER Name: Additional Insured(s) other than Cert Holder Attention: and their interest: Address:

JOB INFORMATION (All operations certificates are not advisable) In order to limit the scope of coverage provided to the parties above, please provide the following information, if applicable:

Job Number: Contract Name: Job Name: Contract Number: Job Description: Phase Number:

Contracting Parties: Job Location:

mailto:[email protected]
mailto:[email protected]

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