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If you would like to print this form and fax it to us instead of sending it electronically, please select "print form"
and fax to us at 941-359-3509. If you have a scanner, you can scan and email to us at insurance@revivepremium.com.
A third option is to Mail it to us at: Encore | 6487 Parkland Drive, Sarasota, FL 34243