• 631.273.4242


321 Oval Drive

Islandia, NY11749


Policy Number: 1000

Carrier: NIBONY

To Whom It May Concern:

This letter authorizes you to release all loss information for the above policy and all others we have had with your Company to the direct attention of Stephanie Kuhn c/o National Insurance Brokerage of New York, Inc., 175 Oval Drive, Islandia, New York 11749.Please fax a copy to Joseph Cormio at (631) 273-8990 and mail a hard copy to Joseph Cormio’s attention.

Please do so in the time allotted by New York State Law No. 3426 which is twenty (20) days.

Should you have any questions or foresee a delay, please contact Andre Abe directly at 86656546546.

Thank you for your immediate attention to this matter.


Matilda Dervishaj

Please sign using a stylus, your mouse, or your finger below to authorize this contract. By electronically signing this document, you agree to the terms established above. After the document is signed, you can proceed to print it.

Print Name