Please complete this online form so that we can send you a letter of self-insurance for the City of Saint Paul or the Saint Paul Regional Water Services.

Contact Information

First Name:*

Last Name:*

Organization/Entity Requesting Information:

Street Address:*

City:*

State: *

Zip:*

Daytime Telephone Number:*

Facsimile Number:

City Department/Entity for which Insurance is being Requested of:*

Event, Contract Number/Project Number (if applicable):

Date of Event or Contract/Project Start Date:

Type(s) of Insurance which needs to be Included:*

Workers Compensation General or Public Liability

Automobile Liability Surety Bond

How do you wish to receive this document?*

Mail Facsimile

Both

Does this letter need to be copied to anyone else? If yes, please provide the contact name, organization and mailing address:

Any other comments or instructions:

Thank you.