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Viewing file:     CertRequest1.doc (62.5 KB)      -rw-r--r--
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Great Neck, NY 11021
516-466-4200 (  HYPERLINK "http://www.butwin.com" www.butwin.com 

fax  516-466-4213   no cover page needed


or exit, save and e-mail to  HYPERLINK "mailto:allstate@butwin.com" allstate@butwin.com 



CERTIFICATE OF INSURANCE 
FAX REQUEST


	
Press TAB to move to each field and type your response


From:
Client Name:
 FORMTEXT      


Contact:
 FORMTEXT      
Agent:
 FORMTEXT      


Phone:
 FORMTEXT      
Phone:
 FORMTEXT      


Fax:
 FORMTEXT      
Fax:
 FORMTEXT      


E-mail:
 FORMTEXT      
E-mail:
 FORMTEXT      







Today s Date
 DATE  \@ "M/d/yyyy"  \* MERGEFORMAT 11/4/2008
Number of additional pages (if any):
 FORMTEXT      




Certificate Holder Name & Address
 FORMTEXT      


 FORMTEXT      


 FORMTEXT      


 FORMTEXT      


 FORMTEXT      




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 FORMTEXT      



Description of Operations / Locations

 FORMTEXT      



Does Certificate Holder need to be listed as an Additional Insured?
 FORMCHECKBOX  Yes      FORMCHECKBOX  No




Are there any other Additional Insureds?  
 FORMCHECKBOX  Yes      FORMCHECKBOX  No

 FORMTEXT      	



Additional comments or instructions

 FORMTEXT      	







Certificates will be sent to the Certificate Holder, the Insured, & the Producer, unless otherwise instructed.



		












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