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Y) Company Name NAIC # Form number(s) Filing date Single Employer Groups Multiple Employer Groups Non-Employer Groups (Check all that apply) Large Group Small Group Association(s) To be used with: Product Type (Some types may be exempt from certain filing requirements as marked by **) Check all that apply. Major Medical Accident Only Dental Vision Supplemental Plan Employer Coverage for Medicare Eligible Only Other Statute/Regulation Re.

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