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Get WI OCI 21-029 2005-2024

WI 53707-7873 (608) 266-3585 Ref: Ch. 611, Wis. Stat. PLEASE COMPLETE AND RETURN TO THIS OFFICE Name of Plan Street Address and/or P.O. Box State City The Zip + 4 Federal Employer ID # hereby applies for a (Name of Plan) license authorizing it to transact the business of insurance authorized under ch. 611, Wis. Stat. The plan operates as the following type of insurer: Traditional Service Insurance Corporation Health Maintenance Organization Preferred Provider Plan Dental Plan (open pa.

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