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Last Name, First Name IN#: Your Agencies Name/Logo Here (Include Address, Phone Number, Tax ID# and NPI#) PLEASE USE THIS REPORT TEMPLATE ONLY (You may include additional information as needed.) Optima:

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What is your agency's name/logo here?

Our agency's name/logo is XYZ Insurance.

Who is required to file your agency's name/logo here?

All licensed insurance agents are required to file.

How to fill out your agency's name/logo here?

You can fill out the form online or submit it via mail.

What is the purpose of your agency's name/logo here?

The purpose is to ensure compliance with regulations and track licensed agents.

What information must be reported on your agency's name/logo here?

You must report your contact information, license number, and any updates to your licensing status.

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