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
5. Their Mail Address
7. Residential Address
8. Phone Number
9. Fax Number
10. Type of policy for Certificate: 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