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Gent is listed here. 2. Section TWO is completed by the writing/field agent. This portion MUST be completed and signed by the original broker. 3. DO NOT complete section THREE 4. Questions should be directed to Jim Martin at extension x23864 280 N High St. Suite 300 Columbus OH 43215-2535 (800) 444-1744 phone (877) 444-4094 fax www.iiibrokerage.com Form BR-7 AFFIDAVIT BY ASSURED Affidavit # 20 I/We of do hereby state that in.

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