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\cltxlrtb\clftsWidth3\clwWidth3067\clshdrawnil \cellx3060\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7463\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 YOUR NAME\cell {\*\bkmkstart Text2}}
{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname 
Text2}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid1705010 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 
\f43\insrsid4076902 {\*\bkmkend Text2}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow1\irowband1\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt
\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3067\clshdrawnil \cellx3060\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7463\clshdrawnil 
\cellx10523\row \ltrrow}\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 YOUR PHONE/FAX\cell {\*\bkmkstart Text3}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 
000000001400000005546578743300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid1705010 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text3}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow2\irowband2\lastrow \ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3067\clshdrawnil \cellx3060\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7463\clshdrawnil \cellx10523\row }\pard\plain \ltrpar
\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\par What company/organization is requesting the certificate of insurance}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355  from you}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 ?
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth10530\clshdrawnil \cellx10523\pard\plain \ltrpar\s15\qc \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid4076902 CERTIFICATE HOLDER INFORMATION}{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid15153807  (Who is requesting the insurance from you)}{\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid4076902 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl
\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth10530\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow1\irowband1\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl
\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 COMPANY NAME\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Text4}{\field{\*\fldinst {\rtlch\fcs1 \af43 
\ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af43 
\ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 
{\*\bkmkend Text4}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow1\irowband1\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow2\irowband2\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 ATTENTION:\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Text5}{\field{\*\fldinst {\rtlch\fcs1 \af43 
\ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743500000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text5}}}}}{\fldrslt {\rtlch\fcs1 \af43 
\ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 
{\*\bkmkend Text5}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow2\irowband2\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 STREET ADDRESS\cell 
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Text6}{\field{\*\fldinst {
\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743600000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text6}}}}}{\fldrslt {
\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 
\f43\insrsid4076902 {\*\bkmkend Text6}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow3\irowband3\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 TOWN\cell {\*\bkmkstart Text7}}
{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname 
Text7}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 
\af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text7}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow4\irowband4\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 STATE\cell {\*\bkmkstart Text8}}
{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743800000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname 
Text8}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 
\af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text8}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow5\irowband5\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 ZIP\cell {\*\bkmkstart Text9}}
{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname 
Text9}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 
\af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text9}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow6\irowband6\lastrow \ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth2700\clshdrawnil \cellx2693\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth7830\clshdrawnil \cellx10523\row }\pard\plain \ltrpar
\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat21 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 Is this certificate request relating to an equipment lease? \tab \tab {\upr{\*\bkmkstart ??????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4043 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4043 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname 
\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4043 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 Yes\tab {\upr{\*\bkmkstart ??????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4042 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4042 ?}}}}}
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 0100000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20
{\upr{\*\ffname ??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4042 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid4076902  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 No
\par }{\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid4076902 If no, skip to the next section.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902           If yes, provide the following information:
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 LEASE NUMBER\cell 
{\*\bkmkstart Text10}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text10}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text10}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow1\irowband1\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 LEASE EFFECTIVE DATE\cell 
{\*\bkmkstart Text11}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313100000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text11}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text11}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow1\irowband1\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 LEASE TERMINATION DATE\cell 
{\*\bkmkstart Text12}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313200000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text12}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text12}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow2\irowband2\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow3\irowband3\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trkeep\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl
\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 TYPE OF EQUIPMENT\cell {\upr{\*\bkmkstart ??????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4041 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4041 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname 
\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4041 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 {\*\bkmkend Check7}  Computer\tab     
{\upr{\*\bkmkstart ??????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4040 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4040 ?}}}}}{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname 
??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4040 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
{\*\bkmkend Check8}  Copier\tab   {\upr{\*\bkmkstart ??????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4039 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4039 ?}
}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4039 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 {\*\bkmkend Check9}  Postage Meter\tab \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\trowd \irow3\irowband3\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trkeep\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow
}\trowd \irow4\irowband4\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trkeep\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvmrg\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth450\clshdrawnil \cellx4043\clvertalb\clbrdrt\brdrtbl \clbrdrl
\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx6023\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth4500\clshdrawnil \cellx10523
\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \cell 
{\upr{\*\bkmkstart ???????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4040 ?}}}}{\upr{\*\bkmkend ???????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4040 ?}}}}}
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000073f3f3f3f3f3f3f00000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ???????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4040 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 \cell }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 Other \endash  Describe:\cell {\*\bkmkstart Text21}}{\field{\*\fldinst {
\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874323100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text21}}}}
}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 
\ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text21}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow4\irowband4\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trkeep\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvmrg\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth450\clshdrawnil \cellx4043\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl 
\clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx6023\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth4500\clshdrawnil \cellx10523\row \ltrrow
}\trowd \irow5\irowband5\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl 
\clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 BRAND NAME\cell {\*\bkmkstart Text13
}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20
{\*\ffname Text13}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {
\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text13} \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow5\irowband5\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow6\irowband6\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 MODEL NUMBER(S)\cell 
{\*\bkmkstart Text14}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313400000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text14}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text14}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow6\irowband6\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 SERIAL NUMBER(S)\cell 
{\*\bkmkstart Text15}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313500000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text15}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text15}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow7\irowband7\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 REPLACEMENT VALUE\cell 
{\*\bkmkstart Text16}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 
0008000014000000065465787431360000001524232c2323302e30303b2824232c2323302e303029000000000000000000}{\*\formfield{\fftype0\fftypetxt1\ffhps20{\*\ffname Text16}{\*\ffformat $#,##0.00\'3b($#,##0.00)}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 
{\*\bkmkend Text16}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid4076902 \trowd \irow8\irowband8\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl
\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row 
\ltrrow}\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
OTHER RELEVANT INFO\cell {\*\bkmkstart Text17}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313700000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text17}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text17}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow9\irowband9\lastrow \ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth3\trwWidth10530\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row }\pard\plain \ltrpar
\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid8278355 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355 Is this company/organization }
{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid8278355 requiring}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355  loss payee status? \tab \tab {\upr{\*\bkmkstart ??????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4045 ?}}}}
{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4045 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 
{\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4045 ?}}}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355 Yes\tab {\upr{\*\bkmkstart ??????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4044 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4044 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid8278355  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname 
\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4044 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8278355 No
\par Is this company/organization }{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid8278355 requiring}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355  additional insured status? \tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 
 FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname 
\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8278355 Yes\tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355 No
\par }\pard \ltrpar\s16\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid10951110 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10951110\charrsid15761306 
If additional insured status is required, be sure to send the contract or agreement with your COI request.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10951110 
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid8278355 {\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\fs20\insrsid8278355 
Note: Naming an additional insured on your insurance policy is not desirable and should only be done when absolutely necessary!
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat21 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 Is this certificate request relating to the use of another\rquote s premise to hold an event?    {\upr{\*\bkmkstart ???????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4047 ?}}}}{\upr{\*\bkmkend ???????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4047 ?}}}}}{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 0100000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\upr{\*\ffname ???????}
{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4047 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  }{
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 Yes\tab {\*\bkmkstart Check12}{\*\bkmkend Check12}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 {\*\datafield 
650000001400000007436865636b313200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check12}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 
\af0 \ltrch\fcs0 \f10\insrsid4076902  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 No        
\par }{\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid4076902 If no, skip to the next section.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902           If yes, provide the following information:
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-7\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr
\brdrtbl \cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 DATE(S) OF EVENT\cell 
{\*\bkmkstart Text18}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313800000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text18}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text18}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\pard\plain \ltrpar
\s15\ql \li0\ri0\widctlpar\intbl\tqdec\tx0\wrapdefault\faauto\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 EVENT DESCRIPTION/TITLE\cell 
{\*\bkmkstart Text19}}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874313900000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text19}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid1705010 \u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {
\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text19}\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow1\irowband1\lastrow \ltrrow
\ts11\trgaph115\trrh-331\trleft-7\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind108\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl 
\cltxlrtb\clftsWidth3\clwWidth3600\clshdrawnil \cellx3593\clvertalb\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth6930\clshdrawnil \cellx10523\row }\pard\plain \ltrpar
\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid8278355 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355 Is this company/organization }
{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid8278355 requiring}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355  additional insured status? \tab {\upr{\*\bkmkstart ??????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?}}}}
{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 
{\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?}}}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355 Yes\tab {\upr{\*\bkmkstart ??????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?}}}}{\upr{\*\bkmkend ??????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid8278355  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355 {\*\datafield 6500000014000000063f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ??????}{\*\ud{\*\ffname 
\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid8278355  }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8278355 No
\par }\pard \ltrpar\s16\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid10951110 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10951110\charrsid15761306 
If additional insured status is required, be sure to send the contract or agreement with your COI request.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10951110 
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid8278355 {\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\fs20\insrsid8278355 
Note: Naming an additional insured on your insurance policy is not desirable and should only be done when absolutely necessary!
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat21 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 If certificate is neither for an equipment lease nor a use of premise, please call Risk Management with details (287-3351}{
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8278355  or 1-800-525-1252}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 ).
\par }\pard\plain \ltrpar\ql \li0\ri0\sb120\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid13126904 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid4076902 It is our practice to }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5112971 e}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6957557 mail the certificate to }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5112971 
you and have you distribute it as needed}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 .  Is this how you want this certificate handled?\tab {\upr{\*\bkmkstart ???????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4045 ?}}}}{\upr{\*\bkmkend ???????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4045 ?}}}}}{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname 
???????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4045 ?}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 
 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 Yes   {\upr{\*\bkmkstart ???????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4044 ?}}}}{\upr{\*\bkmkend ???????}
{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4044 ?}}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 
6500000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ???????}{\*\ud{\*\ffname \u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4044 ?}}}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 No  \tab \tab If no, how do you want it handled?
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-97\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5112971\tblind18\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth540\clshdrawnil \cellx443\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth4417\clshdrawnil \cellx4860\clvertalb\clbrdrt\brdrtbl \clbrdrl
\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth450\clshdrawnil \cellx5310\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth5213\clshdrawnil \cellx10523\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\upr{\*\bkmkstart ???????}{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4039 ?}}}}{\upr{\*\bkmkstart ???????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4048 ?}}}}{\upr{\*\bkmkend ???????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4039 ?}}}}{\upr{\*\bkmkend ???????}
{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4048 ?}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 
0100000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\upr{\*\ffname ???????}{\*\ud{\*\ffname {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4047 ?\u-4039 ?}}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 \cell }\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5112971 Mail a copy to the Certificate Holder}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ???????}{\*\ud{\*\ffname 
{\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4048 ?}}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 \cell 
}\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 Fax a copy to }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11818648 C}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 ertificate }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11818648 H}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 older\cell 
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 
\trowd \irow0\irowband0\ltrrow\ts11\trgaph115\trrh-331\trleft-97\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5112971\tblind18\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl 
\clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth540\clshdrawnil \cellx443\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth4417\clshdrawnil \cellx4860\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl 
\clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth450\clshdrawnil \cellx5310\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth5213\clshdrawnil \cellx10523\row \ltrrow
}\trowd \irow1\irowband1\lastrow \ltrrow\ts11\trgaph115\trrh-331\trleft-97\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind18\tblindtype3 \clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr
\brdrtbl \cltxlrtb\clftsWidth3\clwWidth540\clshdrawnil \cellx443\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx2423\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth8100\clshdrawnil \cellx10523\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\upr{\*\bkmkstart ???????}
{\*\ud\uc0{\*\bkmkstart {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4047 ?}}}}{\upr{\*\bkmkend ???????}{\*\ud\uc0{\*\bkmkend {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4047 ?}}}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 
\af0 \ltrch\fcs0 \f10\insrsid4076902  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 {\*\datafield 6500000014000000073f3f3f3f3f3f3f00000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\upr{\*\ffname ???????}
{\*\ud{\*\ffname {\uc1\u-4029 ?\u-3992 ?\u-3995 ?\u-3997 ?\u-3989 ?\u-4046 ?\u-4047 ?}}}}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f10\insrsid4076902 
\cell }\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 Other \endash  describe:\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 
{\*\bkmkstart Text20}{\field{\*\fldinst {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902  FORMTEXT }{\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\datafield 00000000140000000654657874323000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text20}}}}}{\fldrslt {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4076902 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af43 \ltrch\fcs0 \f43\insrsid4076902 {\*\bkmkend Text20}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902 \trowd \irow1\irowband1\lastrow \ltrrow\ts11\trgaph115\trrh-331\trleft-97\trftsWidth1\trftsWidthB3\trpaddl115\trpaddr115\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind18\tblindtype3 \clvertalb\clbrdrt\brdrtbl 
\clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth540\clshdrawnil \cellx443\clvertalb\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx2423\clvertalb
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth8100\clshdrawnil \cellx10523\row }\pard\plain \ltrpar
\s15\ql \li0\ri0\sb120\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid13126904 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 Complete and e-mail to Risk Management }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12412566 Division (}{\field{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10903159  HYPERLINK "mailto:}{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid10903159\charrsid10903159 jen.maddox@maine.gov}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10903159 " }}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs17\ul\cf2\insrsid10903159\charrsid5848101 jen.maddox@maine.gov}}}\sectd \ltrsect
\psz1\linex0\headery450\footery495\sectdefaultcl\sectrsid10951110\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13126904 ) }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4076902  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13126904 OR }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid4076902 Fax to 287-4008.
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\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 2;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 2;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 2;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 3;
\lsdpriority47 \lsdlocked0 List Table 2 Accent 3;\lsdpriority48 \lsdlocked0 List Table 3 Accent 3;\lsdpriority49 \lsdlocked0 List Table 4 Accent 3;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 3;
\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 3;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 3;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 4;\lsdpriority47 \lsdlocked0 List Table 2 Accent 4;
\lsdpriority48 \lsdlocked0 List Table 3 Accent 4;\lsdpriority49 \lsdlocked0 List Table 4 Accent 4;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 4;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 4;
\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 4;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 5;\lsdpriority47 \lsdlocked0 List Table 2 Accent 5;\lsdpriority48 \lsdlocked0 List Table 3 Accent 5;
\lsdpriority49 \lsdlocked0 List Table 4 Accent 5;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 5;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 5;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 5;
\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 6;\lsdpriority47 \lsdlocked0 List Table 2 Accent 6;\lsdpriority48 \lsdlocked0 List Table 3 Accent 6;\lsdpriority49 \lsdlocked0 List Table 4 Accent 6;
\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 6;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 6;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 6;\lsdsemihidden1 \lsdunhideused1 \lsdpriority99 \lsdlocked0 Mention;
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