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Elephone number ( ) Check entity type: Corporation Partnership Limited Liability Company Limited Liability Partnership Individual Other (specify) List the policy number, name of each nonadmitted insurance company, and the type of coverage for each contract entered into or renewed during the calendar quarter checked above. (Attach additional sheets as needed.) Tax 1 2 2 3 4 5 6 Computation Premiums paid or to be paid on risks located entirely.

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