Proof of Insurance Certificate

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 below, complete the form and submit

These certificates will be sent directly to the land/facility owner(s) 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 the 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)

Questions:

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 problems with our insurance agent, contact:

Dick Tombrink
2250 North 12th Road
Worden, MT 59088
(406) 967-6687
dicknsue@nemontel.net