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Applicant Name NAIC No. FEIN Uniform Consent to Service of Process Original Designation Amended Designation must be submitted directly to states Insurer Name Previous Name if applicable Home Office Address City State Zip NAIC CoCode The entity named above organized under the laws of for purposes of complying with the laws of the State s designate hereunder relating to the holding of a certificate of authority or the conduct of an insurance busine.

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