General Insurance Agency, Inc.
Request for Certificate of Insurance

Please provide the following contact information (all information is required):

Contact Name
Title
Organization Name
Mailing Address
Address (cont.)
City
State
Zip/Postal Code
Station Phone	xxx-xxx-xxxx
Home or Cell Phone	xxx-xxx-xxxx
E-mail
Reason for Certificate
Certificate Holder
Name:
Company:
Address:
City:
State:
Zip Code:
Instructions (Fax # or E-mail address to send Certificate to:

By submitting the above information, you are attesting that you are an authorized delegate of the organization to make changes to your policy and the contact information we have on file matches the information you are sending.  Should any discrepancies be noted between our records and your submission, no change will be made until it can be verified.

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General Insurance Agency, Inc.
Copyright © 2008 [General Insurance Agency, Inc.]. All rights reserved.
Revised: 11/19/08