Roofing Installation Certification Form – Fill Out and Use

Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums

Notice to Homeowner. Completion of this certificate may entitle you to a reduction in your residential insurance premium. This certification form is solely for the purpose of enabling residential property owners to apply for a reduction in their residential insurance premium and it is not to be construed as any type of express or implied warranty by the manufacturer, supplier, installer, or State Farm Fire and Casualty Company. Premium reductions are not available for roofs (other than qualifying metal roofs) that have been overlaid onto existing roofs.

Note: To receive a premium reduction for qualifying metal products, you must sign an endorsement (“Exclusion of Cosmetic Loss to Metal Roof covering caused by Hail”). See your agent for details.

Name of Roofing Company:

Street Address:

City:				County:			ZIP Code:
Phone:			License Number if any:

Address of Residence (Installer/Inspector must complete the following information before signing form)

Name of Owner:

Home Phone:

Address:

Office Phone:

City:

County:

State:

ZIP Code:

Policy Number:

I,

, an authorized representative of

Print Name

Print name of Company

roofing company, do hereby certify that I have inspected or installed, in accordance with the manufacturer’s specifications on the above described residence, a roof shingle, tile, panel, sheet, etc. appearing on the State Farm® Qualifying Roofing Products Listing as of the date of installation. It is listed as complying with Underwriters’ Laboratory Standard 2218, Impact Standard for Impact Resistance of Prepared Roof Covering Materials, or as complying with Factory Mutual Standard 4473, Specification Test Standards for Impact Resistant Testing of Rigid Roofing Materials by Impacting with Freezer Ice Balls. The impact resistant roof covering was installed over the entire roofing surface, including the main areas of the roof and the hips and ridges (including the ridge vent systems). The physical properties of the product used in hip and ridge applications must be of like kind and quality to that of the installed approved product. The roof covering has not been overlaid onto existing roofing material (other than qualifying metal roofs), and is free of defects or damage, including hail damage.

After January 1, 1999 for UL Standard 2218 approved products, and after July 1, 2005 for FM Standard 4473 approved products, each individual shingle, tile, shake, panel, sheet, etc. must be labeled with the following information. In signing on the line below, the contractor agrees that the roof covering product packaging indicates either the UL classification under UL Standard 2218 or the FM classification under FM Standard 4473, the manufacturer’s name, the date of manufacture, and the brand name, and that a label from the packaging has been supplied to the owner of the residence. The contractor also agrees that each individual shingle, tile, shake, panel, sheet, etc. of roof covering is separately labeled with either the UL Standard 2218 classification, or the FM Standard 4473 classification, and with the manufacturer’s name, the date of manufacture, and brand name.

Original Signature of Roofing Company’s Authorized Representative

Date

Any intentional misrepresentation relating to the completion or presentation of this form constitutes fraud.

One copy to be retained by Homeowner

Second copy to Insurance Company

530-645 b.2 Printed in U.S.A. Rev. 05-31-2007