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Wallingford, CT 06492
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Insured Information
Insured Making Request:
Date:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:
Recipient Information
Please issue Certificate of Insurance to the following:
Name:
Address:
City:
State:
Zip:
Attention:
Job Reference:
Do you want Certificate faxed?:
Yes
No Fax #:
Certificate Information
Policies to Reference
*
:
Auto
Umbrella
General Liability
Equipment
Workers' Comp.
Builders Risk
*
Unless you specify differently, Auto, General Liability and Workers' Comp will be
the only policies indicated on Certificate (when applicable)
Additional Insured:
Yes
No
If YES, Specify which policies and give details below:
Waiver of Subrogation:
Yes
No
If YES, Specify which policies and give details below:
30 days Notice of Cancellation:
Yes
No
Special Instructions
Please give any special instructions you feel appropriate for this certificate.
Please click on the
"Submit Request"
button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.
* Securities and investment advisory services offered though ING Financial Partners, Member SIPC
Corcoran and Mann or Consolidated Insurors, Inc is not a subsidiary of
nor controlled by ING Financial Partners.
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