Roofing Installation Certification Form
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NOTICE TO HOMEOWNER: Completion of this certificate will entitle you to a credit on your
residential insurance premium. This form is solely for the purpose of enabling residential
property owners to obtain a credit on their residential insurance premium and it is not to be
construed as any type of express or implied warranty by the manufacturer, supplier or installer.
Roofing Installation Certification
Name of Roofing Company
Street Address
City, State, Zip
Phone
License # (if any)
)
Address of Residence (Installer must complete the following information before signing form.
Name of Owner
Home Phone
Address
Work Phone
City, State, Zip
I,
, an authorized representative of
Print Name of Representative
, do hereby certify that
Print Name of Roofing Company
I have installed in accordance with the manufacturer's specifications on the above described
residence a roof covering listed as complying with Underwriters' Laboratory Standard 2218,
Impact Standard for Impact Resistance of Prepared Roof Covering Materials with an impact
resistance classification of:
Class 1
Class 2
Class 3
Class 4
Manufacturer's Name
Brand Name
Year Manufactured
Date of Installation
The roof covering installed on this residence meets one of the following requirements:
The roof covering product packaging indicates the U.L. Classification under U.L. Standard
2218, the manufacturer's name, the date of manufacture, and the brand name. A label
from the packaging has been supplied to the owner of the residence; or
The metal roof covering is 26 gauge or thicker material, and is installed over solid
underlayment.
Original Signature of Roofing Company's Authorized Representative
Date
Policyholder's Signature
Date
One copy for Insurance Company
Second Copy to Policyholder
OFB 8350
09-12
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Parent category: Business