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Le items must be answered. Responses in the shaded area indicate noncompliance with Section 3404 of the Insurance Law. Form, page and paragraph references that bring the submission into compliance must be included. Failure to complete all items, or responses in the shaded area, will result in this filing being returned without further review. a. Is name and home address of insurer(s) printed on policy? YES NO b. Does first page have amount of insurance, rates, premiums? YES NO c. Is po.

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