Stratum Insurance Agency

Request A Certificate of Insurance

POLICY NUMBER:
	(if you do not know your policy number, please write in the name of your insurance company)
Type of Request

For which type of policy do you need the certificate?

Do you have a written contract or agreement that requires you to add an additional insured?

Company Name:
First Name:
Last Name:

NEW Address:
NEW City:
NEW State:
NEW Phone:
NEW Zip Code:
E-mail:
Confirm E-mail:


Special Comments or special wording that the contract requires:

	Please also email us a copy of the contract or fax it to 949-270-0608.

	If you are just requesting a certificate with no additional insured wording, have blanket additional insureds or there is no charge to add an additional, we will send your certificate.





	Most changes are processed in 24-72 hours, as needed. You will receive a confirmation email once your change has been completed.