Certificate of Insurance

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Certificate of Insurance Questionnaire

This form must be filled out in full to receive certificate

Certificate Holder's Name

Certificate Holder's Address

Your Email

Is the certificate holder to be named as an Additional Insured (may be an additional charge)

Description of Job

Start Date of Job

End Date of Job

Length of Job

Or is this for an annual license renewal?

Location (address) of Job

Cost of Job

Description of Operations to read

Fax to

Or E-mail to

Cert is requested for

GL WC BA PR

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