Read C105 Form text version

Facsimile Transmittal

190 River Road CN1011 Summit, NJ 07902 TEL 866-454-9676 Toll Free TEL 908-598-5600 FAX 908-598-6013

C105.2 Request

In order to obtain a C105 certificate you must complete the attached form and fax it back to us with the original written request from the municipality included. We will not issue the C105 without ALL of the requested information; do not leave ANY selections blank/or unchecked. Please complete the following: · Legal Name and street address of the insured (NO P.O. BOXES only street physical addresses) & and work locations as indicated. Must be the insured's physical address. Name and address of entity requiring proof of coverage Business telephone number of the insured NYS Unemployment Insurance Employer Registration Number of the insured UIER number. If the insured has been in business over 6 months they will have an Unemployment number ­ this must be included. FEIN of the insured Name of Insurance Carrier (IMPORTANT! This must be the specific paper the policy is written on not simply the carrier name) Policy number Policy effective period Check one of the boxes under 3d to indicate officers are included or excluded

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Fax or email this information to us with the request from the municipality attached. WE WILL NOT PROCESS C105.2s under any circumstance without ALL OF THE INFORMATION completed properly (every single item). Thank you.


C105 Form

3 pages

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