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License number. See instructions.) *1232000* Period Covered Due Date January 1 - December 31, 2012 March 15, 2013 CHECK ALL THAT APPLY: Initial return Producer s or Self Procured Person s Name Amended return Street Address and/or Post Of ce Box Made estimated payments during the year City State ZIP Code Change of name/address Name of Producer s Company or Employer Tax Computation Check this box if reporting self procured premiums on line 1. 1. Nonadmitted Gross Direct Insur.

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