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Zip:

Interest:

Sanford Insurance
4468 Forsyth Road
Macon, Georgia 31210
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Phone: 478-471-4221
Fax: 478-471-4222
Toll Free: 800-777-8316
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Your Name:

First	Last

Email Address:

Phone Number:

5 Digit Zip:

Account Holder
Insured Name:
Company Name:
Address:
City
State:
Zip:
Certificate Recipient
Recipient Name:
Recipient Address:
Recipient City
Recipient State:
Recipient Zip:
Recipient Phone:
Recipient Fax:
Recipient Email:
Attention:
Job Reference:
Certificate Information
How Should This Be Sent?
Policies to Reference:
Additional Insured:
If Yes, give details and which policies:
Waiver of Subrogation:
If Yes, give details and which policies:
Primary Wording Endorsement:
Policy Number:
Additional Comments or Instructions:

Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Account Holder

Certificate Recipient

Certificate Information