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Request a Certificate of Insurance Your Name: E-mail Address: Telephone Number: Policy Number: Named Insured: Certificate Information: Name of Additional Insured/Certificate Holder: Address City, State, Zip Project Name/Description: Special language requirements or instructions regarding this certificate: Is a License or Permit Bond Required? No    Yes  Limit: How should this certificate be handled? Please mail the certificate to me. Please mail to the certificate holder at the address indicated above. I will pick up the certificate at your office. Please fax the certificate to:        Fax Number:                 Attn:            Please mail to the person/persons indicated below.        Name:                Address:         Please call me for instructions. If you have not received a response from us within one business day, please contact us again.

Home  |   Products  |   Our Companies  |   About Us  |   Our Staff  |   Contact Us  |   Service Center  |   Claims  |   Payment Options  |   Our Privacy Policy   1420 Ford Avenue   Wyandotte, MI 48192 734-285-5600 • 734-285-6416 Fax   22976 West Outer Drive   Dearborn, MI 48124 313-563-7040 • 313-274-4949 Fax Copyright © 2009 • Karn Sitkins Payette Insurance Agency, Inc. Thursday, September 09, 2010