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Get Wic 1107 0610

Gency s Legal Entity Name: (proposed First Named Insured) b. Organization Type: Individual Partnership Corporation LLC Other: c. Federal Employer/Tax ID No.: d. Is the agency a member of the state independent insurance agents association? ......................... Yes No If Yes, provide agency active directory ID No.: e. Date entity established*: / / (month/day/year) *If less than 3 years, attach resume and business plan f. Is coverage requested for any majority owned addition.

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