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An Independent Insurance Agency
866-965-3155
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Fraser Agency, Inc.
375 W. Washington
Stephenville, Texas 76401
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Phone: 254-965-3155
Fax: 254-965-2645
Toll Free: 866-965-3155
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     REQUEST CERTIFICATE

Request for Certificate of Insurance

Certificate Holder Name:  
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E-Mail Address:  
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 Fax:  

Recipient Information
First & Last Name:  
Street Address:  
City, State & Zip:  
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 Fax:  
Attention:  
 Job Reference:  

Do you want certificate faxed?  
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and which policies:  
Waiver of Subrogation:  
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and which policies:  
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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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