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GA NE KS OR TX VT Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of insurance fraud. I hereby CERTIFY that I have read the answers to all parts of this form and to the best of my knowledge and belief the information is complete and correct as given herein. Name of student Signature of claimant parent or guardian if not adult Student s Address While at School CCF-2013W...

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