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ACORD NEW JERSEY WORKERS COMPENSATION INSURANCE PLAN APPLICATION FOR DESIGNATION OF AN INSURANCE COMPANY DATE TM COMPENSATION RATING AND INSPECTION BUREAU 60 PARK PLACE NEWARK NEW JERSEY 07102 973 622-6014 IMPORTANT - FILE IN DUPLICATE Complete fully. At least three non-affiliated companies have declined to provide voluntary coverage. For that reason the employer applies for selection of an insurance company...
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