Certificate of Insurance Request
Copyright      2009 Stephen W. Gersh Insurance Agency, Inc.  All rights reserved.
*Type of certificate?
General Liability
Worker's Compensation
Insured's Name
*Insured Company Name
*Insured Telephone #
*Certificate Holder Name
Contact Name
*Street Address
*City
*State
*Zip Code
Note: Some carriers charge a
fee for Additional Insureds.
Need To Be
Additional Insured?
*Preferred method for receiving certificate?
Fax
Email
Additional requests/instructions
Please note that it takes 48 hours for insurance carriers to
assist us with Worker's Compensation certificate requests.
*Required field