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Get Ga Gid

To acquire this affidavit in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031. Full Name and Address of Private Review Agent (Do Not Use Group Names). In connection with the above-named private review agent, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insu.

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