Certificate of Insurance
Disclaimer: Insurance transactions are NOT effective without acknowledgement from a W.C.I.S. representative.

Click here for a printable version to mail or fax us (Otherwise, proceed below to submit an online form to our e-mail).

Items marked with * important to fill out but not required. Please fill in as much of the online form as you can.

*Contact Name:
 
*Email:
 
 
*Please Issue Certificate To:
 
  Attention:
 
*Company Name:
 
*Address:
 
*City
 
*State
CA
 
*Zip Code:
 
*Phone:
 
  Fax:
 
*Job Name/Number:
 
*Description & Location:
 
  Special Requirements:
  (charges may apply)
Additional Insured Endorsement
Waiver of Subrogation
Primary Wording
Cross out "endeavor to" and "but failure to mail..." in cancellation section of ACORD form
Certificate only
 
*Sending Instructions:
FAX directly to certificate holder FAX #:
 
FAX Certificate to us
 

   

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