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Residence: (Street, City, State, Zip Code). Phone: E-mail: 6. ... an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. I (We) declare ... Net Worth. Federal Tax Status. $0-$24,999. $0-$49,999. $500,000-$749,999. 10%. 33% ... The effective date of this rule is December 14, 1985. 2 ...

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