Certificate of Insurance

Members requiring a certificate of insurance should complete the form below. If the certificate is to name a third party as an additional Covered Party (aka Additional Insured), a contract or agreement must accompany the request and should be emailed to Phuntsok Gaphel of Alliant Insurance Services.

Member Information

Issue Certificate To the Following

Activity Information

Coverage Information

If contract is required, please forward a copy of the agreement/contract/rental application to pgaphel@alliant.com and info@permarisk.gov.

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Waiver of Subrogation

If yes, please forward a copy of the agreement/contract/rental application to pgaphel@alliant.com and info@perma.dst.ca.us.

A waiver of subrogation means your Agency is waiving its right, as well as PERMA’s, to sue the other party if it causes a workers’ compensation claim. Please note: If Statutory coverage, or a waiver of subrogation, is requested, it requires written approval from both LAWCX and PRISM. PERMA needs 3-5 business days to obtain this approval.

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Since these Programs include commercial insurance programs, the broker must make amendatory endorsements to the policy(ies), i.e. adding a Loss Payee, additions to the property schedule, etc. If your agency does not participate in the PERMA programs for these coverages, please contact your agency’s broker for evidence of coverage.

Send Additional Copy

No need to add yourself, as you will recieve an email confirmation. Use the optional fields above for additional recipients of the final certificate.

Contact

Phuntsok Gaphel, Account Executive
Alliant Insurance Services
560 Mission Street, 6th Floor
San Francisco, CA 94105
tel: (415) 403-1447
e-mail: pgaphel@alliant.com