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281-812-8400
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Secure Certificate Request Form
 
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.
Quick Quote Form
 
Name:
First Last
Email:
Phone:
Zip:
Interest:

Contact Information

Lee Insurance Agency
8727 FM 1960 E
Humble, Texas 77346
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Phone: 281-812-8400
Fax: 281-812-8300
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