Hyannis Office 88 Falmouth Rd. * Hyannis, MA 02601 Tel. 508.775.6060 * Fax 508.790.1414
South Dennis Office 485 Rte. 134 * PO Box 1497 * S. Dennis, MA 02660 Tel. 508.398.6060 * Fax 508.394.2267
2. Phone Number
3. Email
4.Name of Entity Requesting the Certificate (Referred to as Certificate Holder in following questions)
5.Certificate Holder's Street Address
7.Certificate Holder Residential Address (if different from mailing address)
8. Certificate Holder's Phone Number
9. Certificate Holder's Fax Number
10. Please describe type of Work to be performed for Certificate Holder: Workers Compensation Liability Commercial Auto Property
11. Additional Insured Status Required (need to note: A charge of $50 to $100 could apply)
12. Questions / Comments