National Insurance Policy 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 not less than 20 business 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 15 on the Insurance FAQ page )

Always check with the person requesting the Certificate to make sure ALL information is correct before submitting the request. If the insurance company is required to process changes to a certificate for an event because of incorrect information, there may be a charge to the branch.

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Branch #

Beginning Date and Time of Event

Date

Time

Event Name

Ending Date and Time of Event

Date

Time

Date the Insurance is Needed No Later Than

Do you need an "Additional Insured Certificate"? (Note: if you choose yes, the land/facility owner automatically gets both certificates.)

Do you need a "Proof of Insurance Certificate"?

Contact Name

Contact Email

Contact Phone

Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Venue/Place Name Where Event Will Be Held

Address of Venue

Address Line 1

Address Line 2

City

State

Zip Code

Land/Facility Owner Name

Attention (Name)

Land/Facility Owner Address

Address Line 1

Address Line 2

City

State

Zip Code

Address Attention Event

Land/Facility Owner Phone

Land/Facility Owner Fax

Land/Facility Owner Email

Specific Wording

Submittor Name

Submittor Position

Submittor Email

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:

Jeff Fenske
1331 10th Ave,
Kingsburg CA 93631
(559) 907-9734
[email protected]