Request a Certificate of Insurance

Sundance Insurance Group

Fill out this form and submit online, or download in XLS format and fax to 702-386-7970. Please allow 24 hours for processing. If urgent, please call 702-270-8277.

Required fields are marked with: *

Your info

Name of person submitting form

Phone number for person submitting form

Email address for person submitting form

Certificate holder info

Contact phone number

Contact name

Insured name *

Certificate holder's name *

Certificate holder's address

(please include Attn: recipient if necessary)

Fax

Certificate request

Job Name/Job #

Job address

Requested additional wording

Must check all that apply

New request
Revision
Residential
Commercial
New tract home
New condo
OCIP/Wrap
For BIDDING purposes

Coverage to be included

General Liability
Auto Liability
Worker Comp
Excess Liability
Auto Physical Damage
Other

Endorsements

Please check all that apply

Gen Liability Additional Insured - see below
Auto Liability Additional Insured
Gen Liability Waiver of Subrogation
Primary Wording
Loss Payee
Work Comp Waiver of Subrogation - provide info below

Job details

Scope of work

Estimated cost

Subcontractor exposure

Duration of job

Estimated payroll

Class code

Terms

I understand that my Liability policy only allows the issuance of Waivers & Additional Insured endorsements when there is a written contract between my company and the certificate holder and understand it is my responsibility to review all contracts.

If OCIP/Wrap-Up job, you agree to send us a copy of the certificate evidencing your enrollment and by marking this checkbox here you are aware that your General Liability policy contains an exclusion for all OCIP/Wrap-Up related work including incidental off-site liability work related to the OCIP/Wrap-Up project.

Binding Agreement

I understand that coverage cannot be bound or altered by this submission request until the information has been specifically confirmed by a Sundance Insurance representative by phone or email.

We respect your privacy. Your information will be sent securely and handled with care.
View our privacy policy.

Note: leave the Subject field blank if you are a real person. If this field is filled in, your request will be ignored. This helps us protect against automated form posts (spam).
Subject

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702.270.8277
8:00 AM - 5:00 PM M-F
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If you need help with this form, or if you'd prefer to make this request by phone or email, please let us know.

Sundance Insurance Group

Our location

9555 Hillwood Dr Ste 140
Las Vegas, Nevada 89134

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