Unique Risk Management & Insurance Services, LLC

Certificate of Insurance Request

Named Insured
Account Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Requested by:
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Requestors Email Address:
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Requestors Fax Number:
Certificate Holder
Name:
Address 1:
Address 2:
City:
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Zip Code:
Delivery Information
Delivery Method (Please select one) Fax  Email
Email Address:
Fax Number:
Attention to:
Required Coverage Information
(*) please provide description below
  Limit Required: Add'l Insured: Add'l Information
General Liability: (*)
Automobile Liability: (*)
Automobile Physical Damage: (*)
Propert/Contents: (*)
Equipment: (*)
Umbrella: (*)
Workers Compensation:
Other:
Required Coverage information description
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Description:
Additional Insured:
please select one		 GL  Auto
Describe Interest of Certificate Holder
Select Interest Type Loss Payee  Mortgagee
Special Instructions:
Please Select: Primary  Non-Contributory
Waiver of Subrogation: GL  Auto  Workers' Comp
Cancellation: Yes  No
If Cancellation (please specify):
Other (please specify):
Certificate Information
Description of Operations:
Insuror Letter:
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Additional Information
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Additional Notes:
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Attention: Please FAX or EMAIL a copy of the contract and insurance requirments to our office. - Select LOCATIONS under WHO WE ARE on our menu for the appropriate contact information.
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CA License #0F56527

Welcome to Unique Risk Management and Insurance Services LLC.  

We are a full service independent insurance agency offering commercial and personal lines as well as employee benefits.

We are committed to providing you with the best possible coverage, tailored to your specific needs at a reasonable cost.

29833 Santa Margarita Parkway
Suite 400
Rancho Santa Margarita , CA 92688

Tel: 949-305-5577 
Fax: 949-305-5077
Toll Free: (877) 2B - Unique 

 

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