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Gent of that Carrier 1a. Legal Name and Address of Insured (Use street address only) Vendor name and address 1b. Business Telephone Number of Insured 1c. NYS Unemployment Insurance Employer Registration Number of Insured 1d. Federal Employer Identification Number of Insured or Social Security Number 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) 3a. Name of Insurance Carrier New York State Office of General Services Design and C.

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