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| Designation | |
| TIN | |
| NCTEA | |
| MFO | |
| Bill sheet | |
| Address |
| Insurance premium | |
| Insurance amount | |
| Insurance policy validity period |
I certify that the information I have provided in this application form is accurate and complete and that I have read the rates and premiums to be paid. In addition, I undertake to notify of any changes to the subject matter of insurance during the term of the Contract.
