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Get PA SWIF-429 2008

Item 18. • If represented by a Broker/Agent, complete Item 19. • Mark “N/A” when not applicable. • Return the completed application to: State Workers’ Insurance Fund, 100 Lackawanna Avenue, P.O. Box 5100, Scranton, PA 18505-5100, telephone 570-963-4635, fax 570-941-2109. • Coverage will become effective as of the date set forth on the Policy of Insurance. 1. Business Name Mailing Address (IF R.D., R.R., OR P.O. BOX, LIST GEOGRAPHICAL LOCATION: INCLUDE SUITE, FLOOR OR APT. NO.

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