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Date: (MM/DD/BY)CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
ABC INSURANCE COMPANY
123 MAIN STREET
ANTON, TEXAS 12345INSURANCE
COMPANY NAME AND
ADDRESSCOMPANIES AFFORDING COVERAGEINSUREDCITY, STATE
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Anytown Texas is a fictional city created for the purpose of this exercise.
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All residents and businesses located within the fictional city of Anytown Texas are required to file.
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