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
*
Business Contact Email
*
example@example.com
Buisness Phone
*
-
Country Code
-
Area Code
Phone Number
Buisness Fax
-
Country Code
-
Area Code
Phone Number
Additionally Insured
Name of Requestor
*
Email of Requestor
*
Phone Number of Requestor
*
Information Regarding Request Dates needed and usage of the Location
Please verify that you are human
*
Submit
Should be Empty: