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CLAIM NO. STATE AND CONTRACT NO. P.O. Box 669 Waverley, IA 506770669 Phone: 800.637.2676 Fax: 608.231.7900 http://www.cunamutual.com Important: The person alleging forgery must complete this form

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Waverly IA 50677-0669 is a zip code for a location in Waverly, Iowa.

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