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A copy of your request will be sent to you by Email

Request for CERTIFICATE of INSURANCE (COI) COPYRIGHT @2017

Your Name *
Your Email Address *
Subject *
 Request Certificate of Insurance ONLY  
 Request Certificate of Insurance and BOND 
Certificate Holder Name

(Person/Company Requesting the COI)
*
Certificate Holder Address *
Certificate Holder Email Address
Certificate Holder Fax Number
Certificate Holder Phone Number
Additional Insured Required?

(Only indicate 'Yes' if this coverage is Required by the COI Holder)
*
 Yes  
  No 
Sections Required:

(Only check those Coverages Required by the COI Holder)
*
 General Liability  
  Automobile Liability  
  Garage Liability  
  Excess/Umbrella Liability  
  Workers Compensation/Employers Liability  
  Other(Property) 
Special Instructions:

Please list any specific instructions for your Certificates or Bonds here:
Email to: INSURANCE@LEUSCH.net
 Sending by Email sample COI and/or Instructions 
Email COI to: *
 Named Insured at My Email Address Above 
 Certificate Holder - Requires COI Email Address Above 
 Both - Requires both Email Addresses Above 
If Bond Delivery Method:
(Cannot Email or Fax)
 Hold in LEUSCH Office for Pick Up by Me 
 Mail to Me 

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Copyrights 1996 , 1997, 2004, 2008, 2009,2010, 2017 
Leusch Insurance Services Agency, Inc.
dba INSURANCE CONCEPTS
All Rights Reserved 
 
Coverage statements in this web site are general descriptions only. The full and exact contract is contained only in the policy. For costs and complete details of coverage, including applicable
exclusions and limitations, call or write our agency.
 
LEUSCH Insurance Services Agency, Inc. is licensed to do business in the following states:
Ohio, Pennsylvania, Michigan, Florida, New York, Texas, Illinois, and Iowa
 
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