Client ResourcesRequest a Certificate Certificate Information Name of Insured* Name of Certificate Holder* Email Address* Policy Number Relationship Between the Certificate Holder and the Named Insured* Address of Certificate Holder (Street Address)* Address of Certificate Holder (City, State, Zip)* Job Information Description of Job* Length of Time Needed* Delivery Information Enter Fax or Email Address Where You Would Like The Certificate Sent* Does the certificate holder need to be listed as additional insured?* YesNoUnknown Policy Type* General LiabilityWorkers CompCommercial AutoDisabilityNeed C105.2 Upload documents Comments “I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of IM Insurance Brokerage.”Please leave this field empty. Call Us About Your Insurance Coverage. Reach Out Now
