Certificate of Insurance

Home / Certificate of Insurance

Certificate of Insurance Questionnaire

This form must be filled out in full to receive certificate

Certificate Holder's Name(Required)

First Last

Certificate Holder's Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Your Email(Required)

Is the certificate holder to be named as an Additional Insured?(Required)

(may be an additional charge)

Yes

Description of Job(Required)

Start date of job(Required)

End date of job(Required)

Length of Job(Required)

One time? Or for annual contract? Etc.

Or is this for an annual license renewal?(Required)

Location of Job(Required)

Street Address City State ZIP Code

Cost of job

Description of Operations to read

Fax to

or Email to

Cert is requested for

CAPTCHA

716.664.3890

[email protected]

716.664.3890

[email protected]

Contact Info

Jamestown

716.664.3890

[email protected]

Mon - Fri 8:30AM - 5:00PM

Saturday & Sunday Closed

205 Fluvanna Ave

Jamestown, NY 14701

Buffalo

716.822.6874

[email protected]

Mon - Fri 8:30AM - 5:00PM

Saturday & Sunday Closed

1926 Clinton St.

Buffalo, NY 14206

Welcome to Cynthia Woltz Insurance Agency, Inc, located in Jamestown, and Buffalo, NY.

Jamestown Office

Buffalo Office

Email

Welcome to Cynthia Woltz Insurance Agency, Inc. We're here to help.

Certificate of Insurance

Certificate of Insurance Questionnaire