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Questions?
Ask the
Agent!

E-mail Questions to: jrumer@rumergroup.com

Toll-Free: 1-888-81-RUMER
Phone: 1-215-918-1882
Fax: 1-215-918-2220

Office Located at:
1432 Easton Road, #3-I
Warrington, PA 18976

Please Issue Certificate of Insurance Per Below: One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name (First, Last)

Business Name (If policy is commercial.)

E-Mail (REQUIRED):

E-Mail (again to verify accuracy):

Phone (REQUIRED):

Fax Number or e-mail where you want this certificate to be sent: (If you enter fax or e-mail, we will fax/e-mail your certificate to this number. Otherwise, we will mail.)

Certificate Details
Your Policy Number: (If you know it, for accuracy)

Name of Cerificate Holder (CH):
CH's Street Address:
CH's City, State, Zip Code:

Does Certificate Holder Require Special Wording?	NO YES


If Special Wording is required, please type it accurately in this space:

If we need further information, how should we contact you?	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please Issue Certificate as Requested. I understand that none of the changes requested are in force until written confirmation is received from the Rumer Insurance and Financial Group.

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!


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