This form is to be used for existing coverages only. This request does not add, extend, alter or bind any coverages not currently in place. If a valid fax number is not included, the original will be mailed to the Certificate Holder and a copy to the Insured. It is our intent to provide the Certificate within 24 hours of a request. If a certificate is needed immediately, please complete and fax the form and then call to notify our office.



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