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5* * Annual premiums quoted. Coverage will be effective the first of month after application approval. Premiums billed will include an additional separate surplus line tax of 3.5% and a stamping fee of .1%. Applicant Information NAME ADDRESS CITY STATE ZIP PLEASE NOTE: The association member is ineligible for this coverage if the member or relative of the member living in the member s household had a DUI, DWI or a suspended license in the past three years. Student members are not eligible.

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