Northeastern Group Policy Service Center

Certificate of Insurance

You may use the form below to submit a request for a Certificate of Insurance directly to one of our qualified agents. An agent from our office will contact you shortly after receiving the request. This feature is only for existing clients who are commercial policy holders.

General Information
Name of Insured:
Insured Phone:  
Name or Company of
Certificate Holder:
Job Reference No.:
Address of Holder:
City:   State:   Zip:
Holder Phone:  
Holder Fax:  
Your Name:
Contact E-mail Address:
Handling Method:

Required Coverages
Please provide copy of insurance requirements of contract:

General Liability (provide description below) 
Workers' Compensation  
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation: Yes   No
Need Endorsements for Primary Wording:

Yes   No
Additional Insured:
Loss Payee:

Comments or Other Instructions

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