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I have given my permission to place my insurance policy with a Type of insurance and policy if available nonadmitted insurer and I acknowledge that in the event of the insolvency of such insurer the policy will not be covered by the Nebraska Property and Liability Insurance Guaranty Association. Policy Effective Date Signature of Insured Date Form must be signed and dated by insured no later than 30 days after the effective date in compliance with Nebraska Statute 44-5510.
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