Request for certificate of insurance

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Request Certificate of Insurance

Certificates requests must include the name and address of the company who is requesting it. We do not necessarily mail the certificates (generally we fax or email) but this information must go in the certificate holder's box on the certificate we send. If you do not know the address of the company, please include their phone number and we will call them for the address.

Certificate requests are generally responded to within 1 hour. All certificates will be sent to you and you can forward it to the appropriate party.

Your Information

Your business name: * Your name: * Phone number: * Fax number: Email address:

Who's requesting it?

Name of company: * Address: *

City: * State: * Zip: *

Phone number: Fax number: Email address: To who's attention?

Additional Insured? Yes No

Waiver of Subrogation? Yes No

Additional Info

If you have a sample certificate of a copy of your contract and want to send it to us, click on the blue folder to choose your file and attach to this form. If you have more than one document, you can click on the blue folder again after each attachment.

Any additional information or comments, add them here:

Security

To finish submitting the form, please enter the characters in the box to the right and press the submit button. It is not case sensitive. If you cannot read the characters, press the blue arrows and new characters will generate.

Thank you for your request. You should receive your certificate within 1 hour. If you do not receive it within that time, please call 210-521-4545.

Thank you for choosing Gemini Insurance Agency.

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