Certification By Insurance Broker Or Agent

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CITY OF NEW YORK
CERTIFICATION BY INSURANCE BROKER OR AGENT
The undersigned insurance broker or agent represents to the City of New York that the attached
Certificate of Insurance is accurate in all material respects.
_____________________________________________________
[Name of broker or agent (typewritten)]
_____________________________________________________
[Address of broker or agent (typewritten)]
_____________________________________________________
[Email address of broker or agent (typewritten)]
_____________________________________________________
[Phone number/Fax number of broker or agent (typewritten)]
_____________________________________________________
[Signature of authorized official, broker, or agent]
_____________________________________________________
[Name and title of authorized official, broker, or agent (typewritten)]
State of ……………………….)
) ss.:
County of …………………….)
Sworn to before me this _____ day of ___________ 20___
_______________________________________________________
NOTARY PUBLIC FOR THE STATE OF ____________________

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