(408) 358-3200
Los Gatos, CA
JP Bernard Insurance Agency
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Your Company Information
Company
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Details
Should we fax the certificate?
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Yes
Email the certificate?
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Yes
Additional Insured
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Yes
If yes, give details
Waiver of Subrogation
No
Yes
If yes, give details
Recipient Information
First & Last Name / Company
Street Address
City
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Zip
Phone Number
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Attention
Job Reference
A detailed description of your operation
Date coverage is needed
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The location of the operation
# of employees
The total amount of payroll for each type of job
Your loss experience (history of your workers’ compensation claims)
State employer #
Have you ever had work comp?
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Yes
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