The Royal Palm Agency
Phone : (561) 210-8460
Fax : (954) 697-8551
Email : info@theroyalpalmagency.com
 
  REQUEST for INSURANCE  
 

 

Insured Name:
   
Name of Requestor:
    
Email Address of Requestor:
    
Date of Request:
    
Name of Certificate Holder:
    
Address of Certificate Holder:
    
       
Fax to Certificate Holder:
  

  |    Fax Number:

       
E-mail to Certificate Holder:
  

  |    E-mail Address:

       
Fax to Insured:
  

  |    Fax Number:

       
E-mail to Insured:
  

  |    E-mail Address:

       
Is Certificate Holder to be Named as Additional Insured:
  

   
If yes, please fax a copy of the insurance section of the contract to our office along with this form
Is a waiver of Subrogation required in favor of the certificate holder:
  

   


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