Certificate of Insurance

Member Information

First Name *

Last Name *

Member Agency *

Title

Email *

Phone

Issue Certificate To the Following

Organization Name *

Attn *

Address *

City *

State *

Zipcode *

Telephone

Email *

Activity Information

Description/Summary of Activity *

Coverage Information

Certificate Required

Proof of Coverage Only (No Contract Required)

Additional Covered Party (Contract Required)

If contract is required, please forward a copy of the agreement/contract/rental application to pgaphel@alliant.com and info@permarisk.gov.

Contract/Activity Start Date *

Contract/Activity Start Time *

Contract/Activity End Date *

Contract/Activity End Time *

This is a multi-year contract (and thus should be marked as a recurring request)

Coverage Type

Auto/General Liability Certificate

$

Workers’ Compensation

Waiver of Subrogation

No

Yes

If yes, please forward a copy of the agreement/contract/rental application to pgaphel@alliant.com and info@perma.dst.ca.us.

A waiver of subrogation means your Agency is waiving its right, as well as PERMA’s, to sue the other party if it causes a workers’ compensation claim. Please note: If Statutory coverage, or a waiver of subrogation, is requested, it requires written approval from both LAWCX and PRISM. PERMA needs 3-5 business days to obtain this approval.

Property Certificate

Auto Physical Damage Certificate

Professional Liability Certificate

$

Since these Programs include commercial insurance programs, the broker must make amendatory endorsements to the policy(ies), i.e. adding a Loss Payee, additions to the property schedule, etc. If your agency does not participate in the PERMA programs for these coverages, please contact your agency’s broker for evidence of coverage.

Please provide any additional information regarding the coverage type and limits

Send Additional Copy

First Name

Last Name

Email