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Y to certify the agency or firm s compliance. Member must be listed on Ownership section. 2. Please complete each line on the form in its entirety to avoid delays in processing your affidavit. If requested information does not apply to your business insert N/A (not-applicable) on that line. 3. List all state Licensing Information on the affidavit that allows you to engage in the insurance business, and attach a copy of your insurance certificate(s) and/or license(s). 4. The person responsible.
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