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Signed at city state Dated Signature of Primary Proposed Insured ICC15 40-260-05053 R07-15 FR.10. 30. My statements and answers are offered as an inducement to grant insurance and I understand that Assurity may use misstatements or misrepresentations in the application to contest the validity of any coverage provided. I further understand that the insurance applied for shall be in force as of the certificate issue date shown on the certificate schedule and not the date the application is...
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To fill out the birth statecountry, follow these steps:
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Locate the section in the form that asks for your birth statecountry.
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Identify your birth country.
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Write the name of your birth country in the designated field.
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What is birth state/country?
Birth state/country refers to the place where a person was born.
Who is required to file birth state/country?
All individuals who were born in a specific state/country are required to report their birth state/country.
How to fill out birth state/country?
You can fill out the birth state/country information on official forms provided by the government or other relevant institutions.
What is the purpose of birth state/country?
The purpose of reporting birth state/country is to accurately document a person's birth location.
What information must be reported on birth state/country?
Individuals must report the specific state or country where they were born.
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