| Mailing Address: Physical Address PO Box 2665 3448 Cleveland Hwy Dalton, Ga. 30722 Dalton, Ga. 30722 706-277-0971 / 800-588-1249 lst@lstins.com |
| ****Changes to your policy can NOT be made with this form, please contact our office for policy change instructions.*** If you are requesting a certificate- we must have the certificate holders name, mailing address and either a email address or fax number. |