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Get PA SWIF-429 2006

UCTIONS: Clear All You must answer all questions completely and correctly. Please type or print. Sign the application as indicated in Item 18. If represented by a Broker/Agent, you must complete Item 19. (Mark N/A when not applicable.) Return the completed application to the State Workers’ Insurance Fund at the address set forth above. Coverage will become effective as of the date set forth on the Certificate of Insurance. Fields 1. Business Name Mailing Address (IF R.D. OR P BOX, AL.

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