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CERTIFICATE OF INSURANCE REQUEST FORM Fax completed form to NO 623-0037 FIELDS WITH AN ASTERISK MUST BE FILLED IN AT ALL TIMES Please allow 7-10 business days for processing. * This is to certify
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Fax completed form to the designated department.
All employees are required to file fax completed form.
Fill out the required fields and submit it via fax machine or online fax service.
The purpose is to report important information to the designated department for processing.
Employee details, reason for filing, and any supporting documents.
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