Tuttle & Traina Insurance Agency, Inc.

Surety & Insurance Services

Richard C. Traina

William B. Tuttle

Thomas D. Moylan

Raoul Cormier
44 Main Street, Post Office Box 489, Sterling, MA 01564
Phone: (978) 422-7700    Fax: (978) 422-8106

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ON-LINE FORM

Request For A Certificate of Insurance

Please complete the form below for a Certificate of Insurance to be sent out for you, and then click on the submit button below to send it to your office. We will process a Certificate of Insurance for you/your company (Insured's Name) and send an original certificate to the Certificate Holder (Name of Certificate Holder). A copy of that certificate will be sent to you.

Date:  
Your Company's Name or Your Name:  
Your Email Address:  
Your Telephone Number:  
     
Name of Certificate Holder:  
Street Address of Holder:  
City, State, Zip:  
Job Name/Property Name:  
Job Location/Address:  
     
Other Special Requirements For Certificate Holder:    
Additional Insured Certificate Holder Listed as "Additional Insured" (ISO Form CG 20 10)
Any Special Wording for "Additional Insured"? Any Form Numbers?  
  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)
Special Wording  Requirements:  
Comments/Instructions  
Special Forms to Attach  

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