Request a Certificate  
Voluntary Policyholders

Note: Brokers may issue a Certificate of Insurance on behalf of their client.  If you prefer to request a certificate directly from A.I.M. Mutual, please fill out the form below.
 
Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of receipt. 

 

 

1. Name, address, telephone number and facilimile number or email address of the INSURED:
2. Name, address, telephone number and facilimile number or email address of the CERTIFICATE HOLDER:
3. Name, address, telephone number and facilimile number or email address of the PRODUCER:
4. Policy Number, Policy Effective Date and Policy Expiration Date
If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number,
Effective Date and Expiration Date for each policy term.