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Policyholder/Applicant s Signature Print Name and Title/Relationship to Applicant ONLY SIGN HERE IF YOU WANT TO DECLINE TERRORISM COVERAGE. Send application with full premium payment to Lavin Insurance Group LLC Attention Kevin S. Lavin P. This insurance has been designed for the equine exposures you as a member of The National Horseman s Benevolent and Protective Association may have. Underwriting Office Berkley Program Specialists 3655 North Point Parkway Suite 625 Alpharetta GA 30005...
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