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  Request a Certificate

Do you need a certificate of your insurance? No problem. Complete the form below, and someone will be in touch with you shortly.

* required fields

* Date: / /
* Your Company Name:
Email:

* Type of Insurance: (check all that apply)

General Liability
Workers Compensation
Umbrella Liability
Property Coverage
 Automobile Coverage
All of the Above
Other

Certificate Holder (Company requesting Certificate of Insurance from you.)

* Company Name:
* Address
* City:
* State:
* Zip Code:

Please fax to this number () /
Please email to this address

Additional Insured Info:(If not same address as above)

Project Description:

Comments:

      
             
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WIC Insurance • 230 Second Avenue • Waltham, MA 02451
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