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1324 Memorial Hwy
Shavertown, Pennsylvania 18708
P:
(570) 696-0700
99 S Market Street
Nanticoke, Pennsylvania 18634
P:
(570) 735-8990
964 Wyoming Ave
Forty Fort, Pennsylvania 18704
P:
(570) 287-0441
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Certificate of Insurance Request
Certificate of Insurance Request
General Information
Name of Insured
*
Name or Company of Certificate Holder
Job Reference Number
Address of Holder
Street Address
Address Line 2
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Required Coverages
Please Provide Copy of Insurance Requirements of Contract
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description
Need Endorsements for Waiver of Subrogation?
Yes
No
Need Endorsements for Primary Wording?
Yes
No
Loss Payee
Yes
No
Mortgagee
Yes
No
Additional Insured
Yes
No
Comments or Other Instructions
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