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OGINO-AIZUMI INSURANCE


Certificate of Insurance
Request Form

NO COVERAGE OF ANY KIND IS BOUND BY SUBMITTING INFORMATION VIA THIS ONLINE FORM

By completing this form, you are acknowledging your understanding of and agreement with these terms
Insured Information
Full Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:
Issue Certificate of Insurance to the following:
Name:
Address:
City:
State:
Zip:
Attention:
Job Reference:
Do you want certificate to be faxed? Yes
No
If Yes,
Fax Number:
Certificate Information
Policies to reference: Auto
General Liability
Umbrella
Equipment
Workers Comp
Builders Risk
Additional Insured: Yes
No
If Yes, please specify which policies and provide details:
30 days notice of cancellation: Yes
No
Any Special Instructions:
Site Mailing List 

Ogino-Aizumi Insurance Agency
1818 W. Beverly Blvd., Suite 210
Montebello, CA 90640
Phone: (323) 728-7488
Fax: (323)724-5611
Email: paul@oginoaizumi.com

 

 

 

 

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