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"""">"Z(CEEEEEE$n!i"iQ~CC:O,0lU "{ /0R"-`""Xii^" :  SHAPE \* MERGEFORMAT  REQUEST FOR CERTIFICATE OF INSURANCE (THIS FORM IS PROVIDED FOR THE CUSTOMER TO APPROVE AND FORWARD TO THEIR INSURERS) DATE: ________________________________ TO: CUSTOMERS INSURANCE AGENT DESCRIPTION OF ITEM(S) TO BE INSURED NAME OF AGENCY __________________________________________________ _____________________________ _____________ ADDRESS ___________________________________________________________ ___________________________________________ _______________________________________________ __________________________________ PHONE _____________________________________________________________ ___________________________________________ FAX _______________________________________________________________ ___________________________________________ AGENT _____________________________________________________________ INSURABLE VALUE _________________________ We have entered into an agreement with the Owner for the above described item(s). This is a NET agreement and we are responsible for the insurance. The insurance policy must include a provision for the following requirements: COMPREHENSIVE GENERAL LIABILITY/PROPERTY DAMAGE COVERAGE: Loss Payee clause information (can not name Certificate Holder as Loss Payee, we need to be named specifically as loss payee): LEASING SERVICES c/o ABIC Lease Insurance Services- 5th Floor PO Box 979280 Miami, FL 33197-9280 Special Form Coverage, All Risk including theft Effective and Expiration of Coverage I authorize the above agent to immediately place the insurance coverage required for the described item(s). Please issue a binder of insurance to the above named additional Insured and Loss Payee by return mail and replace it with the original insurance policy endorsement within 30 days. This Certificate should indicate the following: It is agreed that Leasing Services will be notified in writing 10 days prior to cancellation of other material change in the conditions of this policy. IMPORTANT: Insurance agent please send completed Insurance Certificate by fax: 1-305-259-4577 or e-mail  HYPERLINK "mailto:GAmail@assurant.com" GAmail@assurant.com. You can also mail to the loss payee above. 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