269 Broadway

Malden, MA, 02148

781-322-2886

Call Us: 781-322-2886 Auto + Home + Business Insurance Serving Malden & Greater Boston Since 1996.

Your Custom Text Here

Certificate of Liability Request Form

Certificate of Liability Request Form from Derek Witham Insurance Agency, Inc. (DWIA)

Certificate of Liability Request Form

Please complete the form below and we'll get back to you within 1 Business Day. In order to accurately quote your risk, please verify your information below for its accuracy. All fields with an asterisk (*) are required.

Named Insured

First Name

Last Name

Policy Number

COI Holder, Name and Mail Address

A full description of the work to be done so we can match this against the current coverage:

The job location:

Any exterior work excess of 3 stories in height:

Any Spraying operations:

Any use of equipment such as a Bob Cat, Cherry Picker, Boom Lift, or scaffolding that may result in an additional charge:

Is this insured using/hiring sub or independent contractors:

If Yes to any of the above, provide name of Sub's, job functions, max height, cost paid, confirm sub has provided a COI with equal or higher limits:

Job Start Date

YYYY

Is this one job:

Additional Remarks:

By the name below acting as your E-signature, you attest that this is the only work to be performed for the COI holder indicated above and that any other work not indicated may not be insured by the noted insurance policy, including any defense coverage.

First Name

Last Name

E-Signature belongs to:

Today's Date

YYYY

Certificate of Liability Request Form

VISIT DWIA

CONTACT

GET STARTED

CONNECT