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F): Duration: Alteration Hour Replaces policy: Certificate no./Green card no. h Temporary, ending at 24h00 on Annual, renewable General Data: Insurance Policy Holder Name Address Taxpayer's no. - Postal code City County E-mail Date of birth/Incorporation No. of children Telephone Gender Marital status/Corporate form Mobile Identity document Number Fax Occupation/Activity business Activity code Driver's license Community? Date Yes No Premiums Instalments: In full Annua.

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