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Certification Request Form

(*) Some fields are reqduired based on your prior entries. Please complete the form correctly to ensure prompt service. Incomplete or incorrect submissions can delay processing time.
* Insured Name		*Email
* Submitted by

*Term Dates Requesting (DD/MM/YYYY)
* Certificate Holder Name
*Reference Specific Project
*Contact
*Street Address
*City
*State
*Zip

Send Cerficiate Where?
*Insured	Insured email or fax#:
*Requester Other	Requester email or fax#:
*Other	Other email or fax#:
Other's Name
Additional instructions or special language required
	Required: Please enter the required anti-spam phrases into the field above before sending. Please pay attention to spacing and punctuation. (*) Some fields are required based on your prior entries. Please complete the form correctly to ensure prompt service. Incomplete or incorrect submissions can delay processing time.

Health Insurance in Grand Rapids & West Michigan-The AIC Group