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V. I. N. Make/model/type of vehicle ACV ST AMT Mfg. seating capacity Value of perm. attached equip. Radius Farthest city City state zip where garaged License state License plate No. GVW/GCW Commercial COMP Retail COLL Service Leased Vehicle. Premium. 82. Are any Lessors or other entities to be added as additional insureds. 79. Medical Payments 80. In addition an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. 75. Uninsured...
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