Uw Fax Cover

Fax Cover Sheet Customer Service / Underwriting

®

(This cover sheet can be used to communicate important information to the Titan Customer Service / Underwriting Department.) To :

Titan Customer Service / Underwriting Attention: _____________________________________________________________ Fax: 866.422.2043 Phone: 800.888.8424 / 440.461.3461 Date: _____________________________________________________________

From:

Agency Name: _____________________________________________________________ Attention: _____________________________________________________________ Agency Code: _____________________________________________________________ Address:

_____________________________________________________________

City:

_________________________________ State: _______ Zip: ___________

Phone: ___________________________________ Ext: ______________________ Fax: _____________________________________________________________

Notes: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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Underwritten by: TITAN INDEMNITY COMPANY 5915 Landerbrook Drive • Cleveland, Ohio 44124-4058