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Third-party administrator TPA must be approved by and under contract with Assurity. If a TPA will be involved please provide the information below. Details of any subsidiaries or affiliates to be insured 2. Name and nature of business 3. Type of business C Corporation 4. Company Name 8. Requested effective date of insurance 9. Is this an ERISA Plan Yes / Group/Policy Number Termination Date MM/DD/YYYY No 10. Any person who knowingly and with intent to defraud any insurance company or other...
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