Republix Loss Runs Business Name Business Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year(s) Carrier Policy # UntitledPlease accept this letter as a formal written request for our Loss History. We ask that you email our Loss Run Reports for the above referenced policies for all years we were insured with your company, including the current policy period. Please email the loss runs directly to our email you have on file. Additionally, you have our permission to email all loss run reports directly to Republix Risk Mitigation Insurance Solutions, in order to streamline this process, even if they are not my current Agent of Record. Republix Risk Mitigation Insurance Solutions Email: Colnn@joinrepublix.com Sincerely, ________________________________________ Authorized Representative ________________________________________ Full Name & Title ________________________________________ Date
