Form Swif-411 - Request For Certificate Of Insurance
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1REQUEST FOR CERTIFICATE
DEPARTMENT OF LABOR & INDUSTRY
OF INSURANCE
STATE WORKERS’ INSURANCE FUND
All requests must be submitted in writing using US Postal Service or one of the following:
EMAIL: RA-LI-SWIF-CERTS@PA.GOV
FAX: 570-963-3079 OR 570-941-2109
ATTENTION: POLICY SUPPORT/CERTIFICATES
Date:
From:
Policy Number:
Policyholder’s/Agent’s signature:
Phone Number:
Certificate Holder (requestor of proof of insurance)
Certificate Holder’s Address (complete mailing address including zip code)
Please be advised it is the State Workers’ Insurance Fund’s policy to issue certificates as follows:
•
Brokers/agencies are NOT legally permitted to issue certificates of insurance on SWIF’s behalf
•
Only the policyholder or the Broker of Record may request a certificate
•
The request must provide the policyholder’s or Broker of Record’s contact information
•
Certificates are not issued using ACORD forms; they are SWIF specific
•
Certificates may not be issued blank and not to the policyholder’s name
•
Certificates may only be issued to a specific certificate holder at their physical address and NOT to a job
site location. Certificates will only show proof of PA coverage; no “all states’ endorsements” are issued
•
One certificate covers all job sites for a single certificate holder; job sites may not be listed
•
Certificates cannot be issued with “Its affiliates”, “Subsidiaries”, “DBA”, “In care of”, “Attention/Department
of”, “Additional Insured” nor “Waiver of Subrogation”
•
Certificates are mailed via US Postal Service day after issuance
•
New certificates are mailed to the Insured, Broker of Record and certificate holder. Renewal certificates
sent only to the certificate holder - a list is sent to the Insured and Broker. No certificates are issued
prior to the effective date.
•
If your policy limits or classes are changed, resubmit a request for updated certificates if required
**You may direct any questions PRIOR TO SUBMITTING THE REQUEST to 570.963.4635.
**Note: In the event that the information provided is incorrect or incomplete, issuance of the certificate
may be delayed.
State Workers’ Insurance Fund
100 Lackawanna Avenue | Scranton, PA 18505-5100 | 570.963.4635 |
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
SWIF-411 REV 12-16
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