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Get INSURANCE COMPANY HOLDER REPORT FORM 2009 - Etax Dor Ga

Submit a UP-1Ins for each business included on the CD. ZERO BALANCE REPORTS REQUIRED HOLDER INFORMATION 2. HOLDER (Business Name) 1. FEDERAL EMPLOYER ID# ADDRESS CITY, STATE, ZIP CODE 3. IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER? AND ADDRESS: 5. TELEPHONE 4. NAME OF CONTACT PERSON ( 7. DATE OF INCORPORATION 10. NO. OF EMPLOYESS Y N IF YES, FURNISH AGENT NAME 6. E-MAIL ADDRESS ) 8. STATE OF INCORPORATION 11. ANNUAL SALES/PREMIUMS 9. PRIMARY BUSIN.

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