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POLICY APPLICATION (please print or type) which upon acceptance and approval by NATIONWIDE LIFE INSURANCE COMPANY Columbus, Ohio 43216 will become a part of SPECIFIED HAZARD INSURANCE POLICY NUMBER

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1. Begin by carefully reviewing the instructions provided on the form. These instructions will guide you through the process and explain the purpose and requirements of the form.
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What is on which is form?

Form A-123 is required.

Who is required to file on which is form?

All employees are required to file.

How to fill out on which is form?

The form can be filled out electronically or by hand.

What is the purpose of on which is form?

The form is used to report financial information.

What information must be reported on on which is form?

All income and expenses must be reported.