Additional Insured Certificate of Insurance

1. If a Land/Facility Owner requests a "Proof of Insurance" for a Branch Event, fill out the form below and submit.

2. If the Land/Facility Owner requires to be added as an "Additional Insured", check the "Additional Insured Certificate" box and fill out the form below and submit.

These certificates will be sent directly to the land/facility owners requesting the coverage.

Please submit both of these requests 30 days (not less than 10 days) prior to the date the certificate is needed by the landowner. The insurance agent needs time to process these requests. Requests made at the last minute may not be able to be processed by the time you need it! (see question 19 on the Q & A).

To send by Postal Mail, send to:

If you have any questions regarding our insurance, such as information on Insurance coverage, and requests, information on insurance non-coverage related questions, such as form submittal problems, or if you have problems resolving a problem with our insurance agent, contact:
For questions, contact Johnny Burger 13302 Taylor Orchard Rd., Gentry, AR 72734 (479) 736-5800 jburger370@gmail.com

For all requests for Proof of Insurance Certificates/Additional Insured Certificates, fill out and submit the above form.