Business Quotes, Requests and Other Forms | Report a Claim | Payments | FAQs | Links | Policy Downloads | Request Information Commercial Certificate of Insurance Request Form Upon receipt of the completed form below, A.J. Pijar Insurance will issue a Certificate of Insurance immediately. You, the insured, will receive a "Cc" copy. You are welcome to contact us with any questions. Thank you for your request. Please NOTE: The * noted fields are required to submit this form. * Your Business Name: * Name of Authorized representative making this request: Your Business Federal Identification Number(FID#) * Your Phone Number: Your Fax Number: * Your Email Address: Please complete the following to issue a certificate of insurance: Name of Certificate Holder: Address: City, State, Zip: Attention: Phone Number: Fax Number: Briefly describe the work you will be doing: Is "Additional Insured" status required by written contract Yes No If Yes, please US Mail, Fax or Email the "Insurance requirements" of the written contract ASAP. Please choose the lines of insurance applicable: Commericial General Liability Commercial Umbrella/Excess Liability Business Auto Workers' Compensation Please click the "SEND" button only once.