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
PhoneLicense # (if any)
Address of Residence (Installer must complete the following information before signing form.)
Name of Owner |
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Home Phone |
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Address |
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Work Phone |
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City, State, Zip |
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I, |
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, an authorized representative of |
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Print Name of Representative |
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, do hereby certify that |
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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 |
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Class 3 |
Class 4 |
Manufacturer's Name |
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Brand Name |
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Year Manufactured |
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Date of Installation |
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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.
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Original Signature of Roofing Company's Authorized Representative |
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Date |
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Policyholder's Signature |
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Date |
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One copy for Insurance Company |
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Second Copy to Policyholder |
OFB 8350 09-12 |
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