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Request for Certification of Insurance


University of California
Agriculture & Natural Resources
Office of Risk Services
2801 Second Street
Davis, CA 95618-7774
Ph:  530 750-1263
Fax:  530 756-1113

Coverage types and amounts

Fill in Each category for minimum dollar amount limits required i.e. $1,000,000 (if these limits are not written in the agreement, please contact the party and ask them; they may need to contact their insurance agent)

*Include only if agreement and/or activity require its inclusion.
30 days written cancellation or modification notice is standard with UC's self-insurance programs.
Attach all supporting documents below

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