GSHPA Certificate of Insurance
To request a Certificate of Insurance, please complete the form below. (Allow 10 business days to process your request).Please complete this form accurately. Incomplete or incorrect information could result in a delay. If you have any questions or problems completing this form please contact Member Services at 717.233.1656 or memberservices@gshpa.org
Name of Business
*
Business Address (This is where we will send the Certificate. It can be a different location than the facility requested.)
*
Street Address
Street Address Line 2
City
State/Province
Postal/ Zip Code
Business Contact Name
*
First and Last
Business Contact Email
*
example@example.com
Buisness Phone
*
-
Country Code
-
Area Code
Phone Number
Buisness Fax
-
Country Code
-
Area Code
Phone Number
Additionally Insured
Coverage Period Start Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Coverage Period End Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date does not exceed September 30th, 2027.
Name of Requestor
*
Email of Requestor
*
Phone Number of Requestor
*
Please enter a valid phone number.
GSHPA Contact
First Name
Last Name
GSHPA Contact Email
example@example.com
Additional Information: Usage of location, specific wording needed on certificate, etc.:
Please verify that you are human
*
Submit
Should be Empty: