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I wish to appoint the Bianchi Agency as my agent of record for my policy upon renewal. Their address is:

2301 Milton Ave, Solvay, NY 13219     -     Phone (315)-488-54851 Fax (315)-488-2577

1800 Brewerton Rd Mattydale, NY 13211    -     315-455-5084 Fax 315-410-8991

Utica National 

Name                                       Address                                Phone                            Email

Policy # is _____________________*

Renewal Date ____________________ *

Please fax a copy of my most recent declarations sheet to them at 315-488-2577.

Sincerely,

________________________________

Bianchi Agency - 2301 Milton Ave -  Solvay, NY 13209 - CNYINS@gmail.com

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