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CompanyName:ABCInsuranceCompany DEPARTMENTOFINSURANCE, SECURITIESANDBANKING INSURANCEBUREAU LOCKBOX92180,WASHINGTON, D.C.200902180 Nicole:12345 Tangier:2011EXAMPLEDISTRICTOFCOLUMBIALIFEANDHEALTHINSURANCEGUARANTYFUNDASSESSMENTPREMIUMTAXCREDITCLASSBASSESSMENTRECOVERY
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