Hinman & Associates

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Request Certificate

To request a Certificate of Insurance, complete this form.

Your Name
Date
Insured By
Certificate Holder: (Name and Address)
Description of Job / Auto / Location
Insurance Requirements	Additional Insured on General Liability
	Other (Please Detail)
Mailing Instructions	Regular Mail
	Fax To Certificate Holder Fax #: Attn:
	Fax To Insured Fax #: Attn:
	Email To Email to:
Other Instructions:

• Securities through IBN
  Financial Services, Inc.,
  8035 Oswego Rd. PO Box 2365
  Liverpool, NY 13089
  315-652-4426 or 877-492-9464.
  Member:FINRA & SIPC
• Insurance Products Through
  Oswego Valley Insurance Agencies, LLC.
  166 West 1st Street
  Oswego, NY 13126
  315 430 2633