Business Certificate of Insurance Request Form

Note: We cannot provide any certificate of insurance where GTM is not the broker, or if coverage is not in force at the time of the request.

Your request will be received by our customer service team and processed within one business day.

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* 1. Name of client:

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* 2. GTM Client Account Number:

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* 3. Name of Certificate Holder:

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* 4. Address of Certificate Holder:

Street:

City, State & Zip:

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* 5. Job Description/Location:

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* 6. Certificate is Needed for the Following Coverage: (Select all that apply)

Workers' Comp

DBL

Umbrella

BOP

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* 7. Are They Requesting a C105, U26.3, or Standard Certificate?

C105

U26.3

Standard Certificate

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* 8. Does the Holder Need to be Named Additional Insured? (Additional insured does not apply to workers’ compensation or disability policies)

Yes

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* 9. Is the Holder Requesting a Waiver of Subrogation? (If your policy does not contain a Waiver of Subrogation, an additional fee may apply to add it to the policy)

Yes

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* 10. Do They Need a Statutory or Increased Employer Liability Limit?

Statutory

Increased (additional premium may apply)

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* 11. How Would the Client Like to Receive the Certificate?

Fax

Pick Up

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* 12. Client Email Address or Fax Number:

If the client has the insurance requirement page from their contract, ask them to email it or fax it to you to attach to this request form.

State Fund, ShelterPoint, Hartford and AmTrust Certificates (Rochdale, Technology, Security National, Wesco) can be done within 48 hours.
All others must be requested from the intermediary and can take up to 4 business days for turnaround.

If more information is needed or if policy coverage has to be changed, certificates could take longer.