REQUEST A CERTIFICATE OF INSURANCE

This page is intended for contractors only. If you are looking for assistance with any other business or personal insurance needs, please contact us at 716-662-6166 or send an email to info@wolfagency.com.

Account Number (if you know it):

Date:

Insured's Name:

Name of Certificate Holder:

Certificate Holder Street Address:

City, State & ZIP Code:

Job Name/Property Name:

Location/Address:

Special Requirements?

Yes

No

Certificate Holder "Named Additional Insured" (ISO Form CO 20 10 11 85):

30 Day Notice of Cancellation

10 Day Notice of Cancellation

Special Wording for Banks: "Their Successors and/or Assigns, ATIMA"

ISO Form CG 25 03 11 85 (Separate Aggregate Limit per Project)

Additional Requirements:

Special Forms to Attach:

Comments/Instructions:


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