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: Group Code (if applicable): Domicile: Mailing Address: Company Representative: Representative s Mailing Address (if different from above): Representative s Telephone Number: Representative s Email Address: The above named Insurance Company requests the approval of the Insurance Commissioner of North Carolina to operate as an authorized reinsurer in North Carolina pursuant to North Carolina General Statute ( G.S. ) 58-7-21(b)(4) and certifies that it: (Check the applicable box) Is.
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