For our clients only, if you need a certificate of insurance we want to offer you the option of accessing a certificate request form. Please click here to view and print the PDF file. After filling it out, fax to us at (760) 741-9308, email to one of us under contacts or drop it by our office.
Alternately, print the text below:
SRM Contracting And Paving
INSURANCE CERTIFICATE REQUEST
To: Brouwer Insurance Agency
Ph: (760) 745-5151
Fax: (760) 741-9308
Date: _____ /_______ /______
Sender Name: _______ _______ _________
Your business name: ______________________________________________
Phone: (______) ________________
Email: __________________________________
Certificate holder name: ___________________________________________
Address: ________________________________________________________
Email: _______________________________
Fax #: (______) ___________________
What do they want?
____ Certificate of insurance only (no more info needed)
____ Certificate with Additional Insured (complete below)
Job location: ___________________________________________________
Start/finish dates: _______ — _______ (best guess)
Contract value: $ ____________
Describe your work for this job: _____________________________________
Does this involve new construction on apartments, condos or tract homes? (YES) (NO)
Special terms: (attach info from contract) __________________________________
Send by:
____ Email / fax only
____ Mail original
____ Both
We will provide proof of insurance that you now have with Brouwer Ins. Additional insured and other endorsement forms may have an additional charge.