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Request for Certificate of Insurance
	Certificate Holder Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
	Recipient Information
	First & Last Name:
	Street Address:
	City, State & Zip:
Telephone:		Fax:
Attention:		Job Reference:
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Policies to Reference:
Additional Insured:
If Yes, give details and which policies:
Waiver of Subrogation:
If Yes, give details and which policies:
30 Days Notice of Cancellation:
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Dimond Bros. Insurance Agency, Inc
111 Sheriff St., P.O. Box 1090
Paris, Illinois 61944
Tel: 217-465-5041
Fax: 217-463-3809
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