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Get PA 1609-PR 2012-2024

Exton, PA 19341 Customer ID # Policy # Binder # Report of transactions with unlicensed insurer(s) in accordance with Section 1609 of Article XVI, Surplus Lines of the Insurance Company Law, Act of May 17, 1921, P.L. 682, No. 284, as amended DECLARATION BY PRODUCER Insured Name Location of Risk*** City *Total Insured Value Zip Description of Insured s Operation: Type of Coverage: Amount of Insurance Effective Dates (term) of Coverage State Property* $ Casualty** FROM $ TO ** Gen.

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