Laserfiche WebLink
<br />IN;:'UtiANt;1: rAt; I ;:'HI:1: I <br /> <br />We are in need 0 Certificate of Insurance for the micipality listed below. Please <br />complete this form and return to the following: <br /> <br />Associates Commercial Corporation <br />300 East Carpenter Freeway <br />Irving, Texas 75062.2726 <br />A TTN: Ed Pletzks <br />(214) 541-3313 . <br /> <br />TRANS NO: <br />MUNICIPAll1Y: <br /> <br />BID: <br /> <br />CONTACT: <br /> <br />PHONE: <br /> <br />EQUIPMENT DESCRIPTION: <br /> <br />PARENT INSURANCE COMPANY: <br /> <br />ADDRESS. <br /> <br />CITY: <br /> <br />STATE: <br /> <br />ZIP' <br /> <br />PHONE: <br /> <br />UNDERWRITER/AGENT COMPANY" <br /> <br />ADDRESS: <br /> <br />CITY: <br /> <br />STATE: <br /> <br />ZIP: <br /> <br />CONTACT: <br /> <br />PHONE' <br /> <br />, <br />, <br /> <br />POLICY NO: <br /> <br />EXPIRATION DATE. <br /> <br />PUBLIC UABILlTY AMOUNT: <br /> <br />DEDUCTIBLE' <br /> <br />PHYSICAL DAMAGE AMOUNTS: COMPREHENSIVE: <br /> <br />DEDUCTIBLE' <br /> <br />PHYSICAL DAMAGE AMOUNTS: COLLISION: <br /> <br />DEDUCTIBLE; <br /> <br />INDICATE IF SELF-INSURED, OR IF POLICY IS CONTINUOUS: <br /> <br />. SELF-INSURED FOR: LIABILITY: PHYSiCAL DAMAGE: BOTH: <br />CONTINUOUS UNTIL END OF LEASE/PURCHASE AGREEMENT: YES: NO' <br /> <br />INS-FACT.FIIM <br />