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OFFICE OF ATTORNEY GENERAL Bureau of Consumer Protection (Information Technology Section)

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1
August 2012
OFFICE OF ATTORNEY GENERAL
Bureau of Consumer Protection
INSTRUCTIONS FOR COMPLETING HICPA SELF-INSURANCE CERTIFICATE OF COVERAGE
AND ATTESTATION
Section 517.4(a)(1)(ix) of the Home Improvement Consumer Protection Act, 73 P.S. § 517.1, et
seq. (“HICPA”) requires home improvement contractor applications submitted to the Bureau of
Consumer Protection (“Bureau”) to include:
(ix) Proof of liability insurance covering personal injury in an amount not less than
$50,000 and insurance covering property damage caused by the work of a home
improvement contractor in an amount not less than $50,000. For the purpose of this
subparagraph, proof of insurance may include information attested to by an applicant
that the applicant is self-insured and the bureau shall develop forms for this purpose
and make them available to applicants. The bureau may determine the sufficiency of
the self-insurance and the manner in which it is maintained in compliance with this
act.
Home improvement contractors wishing to register as self-insured must complete, and
attach to their Home Improvement Contractor Registration Application, a Home
Improvement Consumer Protection Act Self-Insurance Certificate of Coverage and
Attestation. This form must be signed by both the home improvement contractor seeking to
register as self-insured and the organization providing the self-insurance.
Please type your answers onto the form, or print neatly in blue or black ink.
Please complete each section. If a question does not apply, please indicate that on the form
(e.g., “not applicable” or “N/A”).
The signed original document (including the Organization’s list of home improvement
contractor members, see page 3) should be mailed along with the Self-insured Member’s
Home Improvement Contractor Registration Application to: Office of Attorney General,
Bureau of Consumer Protection, 15
th
Floor, Strawberry Square, Harrisburg, PA 17120.
Note: Online registration is not available for home improvement contractors registering as
self-insured.
2
August 2012
Please note, that under Section 517.7(a)(11) the Bureau will require that every home
improvement contractor who is self-insured include a statement in every home
improvement contract that they are self-insured, and provide the name, address, and
telephone number of the organization providing the self-insurance.
SELF-INSURANCE ORGANIZATION INFORMATION: This section requires information about the
organization providing coverage for the self-insured home improvement contractor.
Organization name/Phone/Fax/E-mail/Organization address/City/State/Zip Code – This
is the contact information for the organization providing self-insurance coverage for the
home improvement contractor.
Total Number of Organization Members – This is the total number of members of the
organization providing coverage to the home improvement contractor, regardless of
whether they are home improvement contractors.
Total Number of Members Self-Insured by Organization – This is the number of members
of the organization who receive coverage for any purpose, not merely home
improvement work.
Total Years Organization has provided self-insurance – This is the length of time that the
organization has been providing self-insurance of any kind for its members.
Contact Person Name/Title – This is the name and title of an authorized representative
of the organization. The Bureau will contact this individual for any questions or issues
which arise in relation to the organization.
SELF-INSURED MEMBER INFORMATION: This section requires information about the home
improvement contractor who is registering with the Bureau as self-insured.
Self-insured Member Name – This is the home improvement contractor registering as
self-insured.
Member’s business name – This is the trade or business name (if any) used by the home
improvement contractor.
Primary business address/City/State/Zip Code/Telephone/Fax/E-mail – This is the
primary address from which the home improvement contractor does business, as well
3
August 2012
as the phone number, fax, and e-mail address the home improvement contractor uses
for the business.
CLAIM INFORMATION: This section requires information about the representative of the
organization who is responsible for handling claims by consumers against a home improvement
contractor for whom the organization is providing self-insurance coverage.
SIGNATURES: Page 2 of the form must be signed by both an authorized representative of the
Organization and the Member
SELF-INSURANCE ORGANIZATION CERTIFICATION AND ATTESTATION (page 3): The authorized
representative of the Organization should review this page carefully before signing at the
bottom.
The Organization must attach to this Certification and Attestation a current list of its members
who are home improvement contractors and are covered by the Organization. The list must
include the name, business name, and business address of every member self-insured by the
Organization for home improvement work.
If you have any questions regarding this form, please contact the Bureau of Consumer
Protection at (717) 772-2425. Copies of HICPA can be obtained at www.attorneygeneral.gov.
Bureau of Consumer Protection
Pennsylvania Office of Attorney General
15
th
Floor, Strawberry Square
Harrisburg, PA 17120
HICPA Self-Insurance Certification & Attestation Page 1 of 3 August 2012
PENNSYLVAN IA OFFICE O F ATTORNEY G E NE R AL
HOME IMPROVEMENT C O N SU MER P R OTECTION ACT
SELF-INSURANCE CERTIFIC ATE OF COVERAG E AND AT TESTATION
SELF-INSURANCE ORGANIZATION INFORMATION
Organization name:
Phone:
Fax:
E-mail:
Organization address:
City:
State:
Total Number of Organization Members:
Total Number of Members Self-Insured by Organization:
Total Years Organization has provided self-insurance:
Contact Person Name:
Contact Person Title:
SELF-INSURED MEMBER INFORMATION
Self-insured Member Name:
Member’s business name:
Primary business address:
City:
State:
Telephone:
Fax:
E-mail:
CLAIM INFORMATION
Person to whom claims should be sent:
Address:
City:
State:
Phone:
Fax:
E-mail:
CERTIFICATION AND ATTESTATION
By signing below, the above-named Self-Insured Member and the above-named
Self-Insurance Organization through its authorized representative, hereby certify and
attest that the Self-Insured Member is covered by the Self-Insurance Organization for
liability coverage for personal injury and property damage claims related to the Self-
Insured Member’s home improvement contractor business, pursuant to Section
517.4(a)(1)(ix) of the Home Improvement Consumer Protection Act (HICPA), 73 P.S. §
517.4(a)(1)(ix).
The Self-Insurance Organization further incorporates the certifications on the
following pages as part of this document. By signing below, the Self-Insurance
Organization agrees that, should this coverage be cancelled, terminated, or otherwise
ended, the Organization will immediately notify the Bureau in writing of this. By signing
below, the Self-Insured Member agrees that, should this coverage be cancelled,
terminated, or otherwise ended, the Member will immediately obtain insurance as
required under HICPA Section 517.4(a)(1)(ix), or will have the home improvement
contractor registration cancelled and/or revoked.
HICPA Self-Insurance Certification & Attestation Page 2 of 3 August 2012
Please direct any questions to:
Bureau of Consumer Protection
Office of Attorney General
15
th
Floor, Strawberry Square
Harrisburg, PA 17120
717.772.2425
We hereby certify and attest that the information contained in this Certificate and
Attestation is true and correct. I, the authorized representative of the Self-Insurance
Organization, further certify and attest that I have actual authority to make this
Certification and Attestation on behalf of the Self-Insurance Organization identified above.
We also understand that any false statement made herein is subject to the penalties for
unsworn falsification to authorities contained in 18 Pa.C.S. § 4904.
SIGNATURES
AUTHORIZED REPRESENTATIVE OF
SELF-INSURANCE ORGANIZATION
SELF-INSURED MEMBER
_____________________________________
Print Name:
Title:
Date:
______________________________________
Print Name:
Date:
HICPA Self-Insurance Certification & Attestation Page 3 of 3 August 2012
SELF-INSURANCE ORGANIZATION CERTIFICATION AND ATTESTATION
We, the above-named Self-Insurance Organization (“Self-Insurer” or “we”), through our authorized
representative, hereby certify and attest that we will provide coverage for the above-named Self-Insured
Member (“Member”) pursuant to Section 517.4(a)(1)(ix) of HICPA.
We certify and attest that we have provided the Bureau of Consumer Protection (“Bureau”) with a current
list of every Organization Member who performs home improvements as defined under HICPA Section 517.2,
and who are covered by our organization. That list includes each Member’s name, business name (if
applicable), and business address, and is attached hereto as an exhibit.
We certify and attest that, in the event that any valid claim arises against the Member for personal injury or
property damage related to the Member’s work as a home improvement contractor, we will pay such claim
without unreasonable delay.
We certify and attest that we have the financial ability to cover liability claims against the Member in
amounts not less than $50,000 for personal injury and $50,000 for property damage. We further certify and
attest that we have the financial ability to cover liability claims against every other home improvement
contractor similarly covered by the Self-Insurer. We hereby acknowledge that the Bureau may require proof of
our financial ability at any time, and that the Bureau in its sole discretion may determine the nature and
sufficiency of the proof required to demonstrate our financial ability to satisfy the self-insurance requirements of
HICPA. We hereby agree to provide any and all information and documents that the Bureau may request.
Please note, that under Section 517.7(a)(11) the Bureau will require that every home
improvement contractor who is self-insured include a statement in every home improvement
contract that they are self-insured, and provide the name, address, and telephone number of the
organization providing the self-insurance.
We certify and attest that this self-insurance coverage for the Member shall remain in force unless and until
terminated pursuant to the following terms:
1. We may terminate Member’s coverage upon sixty (60) days written notice to the Bureau.
2. We will notify the Member of the cancellation, in writing, sixty (60) days prior to the effective date of
cancellation and remind the Member of the obligation to obtain such other insurance as is
necessary to comply with HICPA, in a timely manner.
3. We acknowledge that such termination will not eliminate our obligation to pay any valid claims for
personal injury or property damage which arose from any home improvement contract signed when
this coverage was in force.
I, the authorized representative of the Self-Insurer, hereby certify and attest that the information contained
in this Certification is true and correct. I further certify and attest that I have actual authority to make this
Certification on behalf of the Self-Insurer identified above. I also understand that any false statement made
herein is subject to the penalties for unsworn falsification to authorities contained in 18 Pa.C.S. § 4904.
____________________________ ____________________________
Date Signature of Authorized Representative
____________________________
Printed Name
____________________________
Title
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Completed 20 April 2022

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