CERTIFICATE REQUEST
Insured or Company Name*
Insured Information
Certificate Holder Information
Address Line 1:
Name*
Address Line 2:
Address Line 3:
City:
State:
Zip Code:
Fax Number*:
Attention:
Special Instructions:
Submitted By*:
Please type the characters you see in the picture in the box below.*

Contact Us

  1. 5214 North Western Ave. Suite 202,  
  2. Chicago, IL 60625
  3. Phone:  773-654-1079
  4. Fax : 773-989-1127
  5. E-mail:  almira@affinityinsure.com

Connect With Us

Customer Login