County Commissioners Association of Pennsylvania CCAP

Certificate Holder

(Requester’s Name and Address Required)

Explanation/Description

(Identification of Project, Event, Vehicle, etc.)

Coverage Requested General Liability Auto Liability Workers’ Compensation Property/Auto Physical Damage Other

Additional Insured

Loss Payee Yes No

Additional Comments Yes No

Form Completed By

First Name

Last Name

Email

U.S. phone number

reCAPTCHA

Certificate of Insurance