Certificate Requests

ZEM INSURANCE SOLUTIONS

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Certificate Request Form

The following information must be completed in order to issue the certificate. Please remember, some information provided will be on the cert. Please complete every field or there may be a delay in processing. Depending on your carrier, there may be additional fees and a possible 2-4 business day delay due to underwriting approval. Our certificate department will contact you the same business day you submit. This is a general form.

Your Company Name: *
Your Company Email: *
Date Needed: *
Choose Cert Type: *
Your Policy Type: *
Cert Holder Name: *
Cert Holder Street: *
Cert Holder City: *
Cert Holder State: *
Cert Holder Zip: *
Orig. mailed to Cert Holder?: *
Cert Holder Mail Address: *
Cert Holder Fax#/Email: *
Cert Holder Contact Name/Number: *
Describe Cert Holder Operations: *
Description of Work Done: *
Residential?: *
New Residential?: *
Commercial?: *
Tracts, Condos, Apartments?: *
Job Cost: *
Job Duration: *
Project Address: *
Is this hourly work?: *
Contract Job?: *
Contract or Job #: *
Primary Wording Required?: *
Waiver of Subrogation Required?: *
Protect Your Information: *
	By clicking this box, you the insured, understand, agree and accept any additional insured certificate charges by your carrier (if any). Zem Insurance Solutions strives to get certificates processed as quickly as possible. Carriers issue the additional insured endorsements and the timeline can be out of our control. Please allow us 24-72 business hours to complete your request.