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Certificate of Insurance

Certificate of Insurance

Insured Information
Insured Name:
Policy Number:
Insured Phone Number:
Certificate Information
Name of Company or Certificate Holder:
Job Reference Number:
Certificate Holder Street Address:
City:
State: Zip:
Certificate Holder Email Address:
Certificate Holder Fax:
(include area code)
Requesters Information
Your Name:
Contact Email Address:
Handling Method:
(if other, please describe in comments area below)
Required Coverages
Please provide copy of insurance
requirements of contract:
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
Yes No
Need Endorsements for Primary Wording:
Yes No
Additional Insured:
Yes No
Loss Payee:
Yes No
Mortgagee:
Yes No
Comments or Other Instructions

By submitting this form you understand that no coverage is bound until you receive written notice. Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Manage Your Policy 
Company Partners
Contact Us

Moss Insurance Group
325 Chesnee Hwy
Gaffney, SC 29341

Phone: (864) 489-8121
Fax: (864) 489-8122

Office Hours:
8:30 am - 5:00 pm
Monday thru Friday

Serving the upstate since 1976.

© Copyright IMPORTANT NOTE: descriptions of insurance coverage on this web site are for informational purposes only and may not apply, or be included on your policy. Please contact us to confirm coverage provided on your insurance policy or policies your are contemplating purchasing. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.
READ OUR PRIVACY STATEMENT

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