FS-1 NORTH CAROLINA CERTIFICATE OF LIABILITY insurance . YEAR MAKE VEHICLE IDENTIFICATION NUMBER. insurance COMPANY NAME COMPANY CODE. POLICY NUMBER. MM DD YYYY. REGISTERED OWNER NAME EFFECTIVE DATE. MM DD YYYY MM DD YYYY. DRIVERS LICENSE DATE OF BIRTH PREPARATION DATE. STREET ADDRESS. TOWN OR CITY STATE ZIP CODE. AUTHORIZED SIGNATURE.
fs-1 north carolina certificate of liability insurance year make vehicle identification number insurance company name company code policy number effective date mmdd yyyy registered owner name
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1 FS-1 NORTH CAROLINA CERTIFICATE OF LIABILITY insurance . YEAR MAKE VEHICLE IDENTIFICATION NUMBER. insurance COMPANY NAME COMPANY CODE. POLICY NUMBER. MM DD YYYY. REGISTERED OWNER NAME EFFECTIVE DATE. MM DD YYYY MM DD YYYY. DRIVERS LICENSE DATE OF BIRTH PREPARATION DATE. STREET ADDRESS. TOWN OR CITY STATE ZIP CODE. AUTHORIZED SIGNATURE.
reason for interest: e-mail address: owner leaseback warranty breach of trustee registrant lien amount: phone (a/c, no, ext): fax (a/c, no): interest end date:
agency customer id: effective date carrier naic code policy number applicant / first named insured agency 4. retroactive date: 3. number of …
The ACORD name and logo are registered marks of ACORD POLICY NUMBER CANCELLED POLICY INFORMATION EFFECTIVE DATE EXPIRATION DATE POLICY TERM EFFECTIVE DATE AND
agent/broker of record change date (mm/dd/yyyy) policy number(s) effective date expiration date named insured line of business (as it appears on policy) please be advised that we wish to name
the undersigned is an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application.
ACORD 80 (2016/11) APPLICABLE IN ARIZONA: Binders are effective for no more than 90 days. APPLICABLE IN COLORADO: The insurer has thirty (30)
ACORD 27 (2016/03) - EVIDENCE OF PERSONAL PROPERTY INSURANCE ACORD 27, Evidence of Property Insurance, provides a coverage statement for mortgagees and loss payees who provide mortgages or loans on
EFFECTIVE DATE YEAR EXPIRATION DATE PREMIUM POLICY NUMBER CARRIER CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: PRIOR CARRIER INFORMATION REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
workers compensation coverage carried (y/n) lease from workers compensation coverage carried (y/n) lease to 17.do you lease employees to or from other employers?
3.if the policy was written without an experience modification factor, please state. 2. 1. or, does this business own a majority interest in another entity, which in turn owns a …
DURATION The National Certificate (Vocational) qualification is a full year program at each of the NQF Levels of study. A student is issued with a certificate on the successful completion of …
REQUEST FOR A CERTIFICATE OF ELIGIBILITY TO Department of Veterans Affairs Eligibility Center P.O. Box 20729 Winston-Salem, NC 27120 NOTE: Please read information on reverse before completing this form.
1006 PRV-2013/09 Solicitor's Final Report and Certificate of Title To: Canadian Imperial Bank of Commerce CIBC Reference No. Mortgagor Civic Address of Property Mortgaged
Do not write in this box CHECK ONE: PENNSYLVAN I ATX UN EX EMPT ON CERT F C (US EF OR NTRANSACTI ) PENNSYLVANIA TAX BLANKET EXEMPTION CERTIFICATE (USE FOR MULTIPLE TRANSACTIONS) Nameof Seller, Vendor, or Lessor Street City State ZIP Code NOTE: Do not use this form for claiming an exemption on the registration of a vehicle. To claim an exemption from tax for a …
DESIGN, CONSTRUCTION, INSPECTION AND TESTING * This box is to be completed only where the design, construction, inspection and testing have been the responsibility of one person.
Certificate of Professional Initiating Involuntary Examination (Page 2) Section III: OTHER INFORMATION Other information, including source relied upon to reach this co nclusion is as follows.
statutory $ (each accident) $ (disease–policy limit) $ (disease–each employee) commercial general products-comp/opsliability claims citymade occur.
es that the claim is based upon the purchaser’s proposed use of the items or services, the activity of the purchase, STEC B Rev. 3/15 . tax.ohio.gov