Certificate Request 
Certificate of Insurance
Insured Information
  Insured Name:  
 
 Policy Number:  
  
 
 Insured Phone Number:  
  
Certificate Information
 
 Name of Company or Certificate Holder:  
  
 
 Job Reference Number:  
  
     
  Certificate Holder Street Address:  
  City:     State:    Zip:  
 
 Certificate Holder Email Address:  
 
 
Certificate Holder Fax:  
   (include area code)
Requesters Information
 
Your Name:  
  
 
Contact Email Address:  
  
 
Handling Method:  
 
   (if other, please describe in comments area below)
Required Coverages  
 
Please provide copy of  
insurance requirements of contract:  
  Auto
  Umbrella
  General Liability 
  Equipment
  Workers' Compensation
  Builders Risk
 
General Liability Description:
     
 
Need Endorsements for Waiver of Subrogation:
Yes   No
 
Need Endorsements for Primary Wording:
Yes   No
 
Additional Insured:
Yes   No
 
Loss Payee:
Yes   No
 
Mortgagee:
Yes   No
Comments or Other Instructions:
 

By submitting this form you understand that no coverage is bound until you receive written notice. Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.
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Site Mailing List 
Serving Virginia For Over 140 Years!

PO Box 306
1404 South Main
Farmville, VA 23901
Phone: 434-392-5405
Email: info@harwoodins.com

 

 

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Community Involvement:

  • Board of Trustees, Hampden Sydney College 2000 – 2013
  • Board of Trustees Randolph-Macon Academy 2002 - 2004
  • Board of Directors, 1st National Bank of Farmville/1st Virginia Bank 1980-1995
  • Virginia Commission of State and Local Governments’ Responsibility and Taxing Authority 1995 – 1996*
  • Commission on the Future of Higher Education in Virginia*
  • Tobacco Indemnification and Community Revitalization Commission 2005 – 2009**
  • Chairman, Prince Edward County United Way, 1988
  • Chairman, Poplar Hill Community Development Authority 2000 – 2004
  • President, Randolph-Macon Academy Alumni Association 2002 – 2004
  • YMCA
  • Farmville Area Chamber of Commerce
  • Farmville Jaycees
  • Farmville Rotary Club
  • Mission work in Honduras
  • Farmville Lions Club
  • Farmville Masonic Lodge
  • Longwood College Center For the Visual Arts
  • Southside Virginia Red Cross
  • Active annually in state and federal lobbying for client and industry advocacy.
  • Veterans of Foreign Wars, Life member
  • Insurance Education for Habitat For Humanity Recipients

 

*Appointed by Governor George Allen
**Appointed by Governor Mark Warner