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Name of Applicant Street Address City State Zip Applicant s Web Site Address 2. Individual Corporation Partnership Other (Explain) 3. List full names of individuals or partners and their interests: 4. Location of premises/operations: Street Address State City 6. 5. Areas of operations (States): 5a. Number of years in business: Zip Prior Insurance/Loss Information: Insurance Company Policy Period 6a. Proposed Effective Dates: 8. Premium # Claims/Amounts Description of pri.

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