Requester Information

Requester Information:

First and Last Name *

Campus or Auxiliary Name *

Email Address *

Notice 4

Please complete the below accordingly.

Date Needed:

Type of Certificate:

Notice 1

Please Note: If your Certificate Holder is requesting to be added as an Additional Insured or Loss Payee, a complete copy of the contract, agreement, or lease must be executed with this request. Please attach contract below or fax to (415) 874-4810.

Attach your Contract:

Coverage: *

*If Other Please Specify:

Limits Requested:

*If Other Please Specify:

Notice 2

Please provide ALL of the following information for the Certificate Holder

Company Name: *

Street Address: *

City, State, Postal Code: *

Contact Person: *

Fax Number: *

Email: *

Please provide location, dates(s) and a description of activity of lease:

Any other special needs:

Notice 3

Please Note: This request will be automatically emailed to the Program Administration Staff at Alliant Insurance, Inc. If this certificate should be issued on a "Rush basis" you should also contact either of the following individuals to be sure they received your request: Van Rin (415) 403-1408 or La Shaunda Wallace (415) 403-1489.

Request Certificate of Insurance

Certificate Request Form

Please fill out the following form to request a certificate

Request Form