EJMS Insurance services – Complete a Certificate

Policy #: (required)

Company Name: (required)

Contact Person Name: (required)

Contact Phone Number: (required)

Contact E-mail Address: (required)

Certholder Name: (required)

Certholder name cont'd:

Attention Line:

Address Line 1: (required)

Address Line 2:

City/State/Zip: (required)

Is the certholder to be named as additional insured?

Yes

Additional insured wording/job/Location Description:

Does the certificate holder require a waiver of subrogation for general liability or worker's compensation?
If so, please complete the following (may require underwriting approval):

General Liability

Worker's Compensation

Waiver in favor of:

Job description:

Cost of job:

Payroll for job:

Do you need this certificate emailed or faxed?

Email:

Fax:

Please upload any documentation (requirements, contacts, etc.) pertaining to the certificate request.

Browse...

Maximum size 10MB

Additional comments/remarks:

This field should be left blank

Please wait...

PLEASE NOTE: The option to list an additional named insured is not available under Workers’ Compensation Insurance.

Complete a Certificate

Instructions

Notice