University of California Agriculture & Natural ResourcesOffice of Risk Services 2801 Second Street Davis, CA 95618-7774 Ph: 530 750-1263 Fax: 530 756-1113
Requesting Party/Preparer Name
(Not Name of a Club) ✻
Requesting Party/Preparer's Email Address ✻
Fax Number ✻
Name of entity to whom certificate
is to be issued ✻
Address of Entity -
City, State & Zip ✻
Effective Date & Time of the Activity: ✻
Expiration Date & Time of the Activity: ✻
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)
Products and Completed Operations Aggregate ✻
Type of event ✻
Comments/Notes:
For verification that you are human, please enter the following code in the box below: ABVGZS
(if the code is not entered correctly, the survey will not be submitted)