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date (mm/dd/yyyy) agent name: carrier naic code: underwriter underwriter off. policies or program requested policy number indicate sections attached
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www.insurancefornonprofits.org NIAC #1
www.gatewayspecialty.comLimit . Premium : Retro Date (if claims made) 2. Is the Applicant a tax-exempt nonprofit organization under the U.S. Internal Revenue Code 501(c)(3), or in the process of obtaining this tax-exempt status?
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