Send completed form to:
State Compensation Insurance Fund
Corporate Communications AV Library
1010 Vaquero Circle
Vacaville, CA 95688
Your completed A/V request form will be process in three (3) working days. Incomplete or inaccurate forms will
be returned. For questions, please e-mail AV Library at
State Agency Name: Date:
State Agency Number:
State Agency Coordinator: Telephone No:
Agency Name:
City, State, Zip:
Attn: Tel. No:
Language Video #-Audio-Visual Title A/V ID #
For Library Use Only
English Spanish
English Spanish
English Spanish
Alternate Choices (Please fill in three alternate choices)
English Spanish
English Spanish
English Spanish
For Library Use Only:
Send Date: Return Date:
Show Date (s): If more than one
day, indicate first and last show
dates. (No ASAP)
Ext. Until:
NOTE: Show date must be completed.
Show dates cannot be longer than one week. If audio-visuals are to
be shown on different dates, use separate request forms. Return A/V immediately through PRIORITY mail
or UPS and insured for $400.00 each after last show date.
A/V: Show Date:
A/V: Show Date:
A/V: Show Date:
e22160 (Rev. 10-12)
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