Instructions |
- Complete all fields on this form. An incomplete form will delay processing.
- If you have cookies enabled in your browser, the Policyholder Information is auto-filled when you submit your next certificate of insurance request.
- Review all data items for accuracy. Double check phone numbers.
- Click the SUBMIT CERT REQUEST button at the bottom of this form.
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Notice |
- Requests received before 2:30 p.m. Pacific Time on a business workday will be processed the same day.
- Requests received after 2:30 p.m. Pacific Time will be processed the next business day.
- For questions about this form or online certificates please contact:
Phone: 408.402.0400 weekdays between the hours of 8 a.m. and 5 p.m. Pacific Time
Fax: 408.402.0401
E-Mail: mail@ejms.com
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Policyholder Information |
Policy #: |
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Company Name: |
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Contact Person Name: |
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Contact Phone Number: |
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Contact E-mail Address: |
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Issue Certificate of Insurance to |
Certholder Name: |
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Attention Line: |
Not Required. |
Address Line 1: |
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Address Line 2: |
Not Required. |
City/State/Zip: |
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Job/Location Description:
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Enter street address, city, state, zip, lot/subdivision, unit number etc.
Press ENTER to start a new line.
Not Required.
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Special Options |
Check all that apply:
(May require
Underwriting Approval) |
Waiver of Subrogation to:
(entity name) Project/Job Description/Name/Contract #
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Increased Liability Limits
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Other
Explain below if the Other box is checked
PLEASE NOTE: The option to list an additional named insured is not available under Workers' Compensation Insurance. |
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Fax Options |
Do you need this
certificate faxed?
(If any fax option is chosen, then we will not mail a separate paper copy) |
Fax Numbers are ignored unless a corresponding box is checked. |
Certholder |
Fax Number |
Policyholder |
Fax Number
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Finished? |
