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Insurance Binder Form

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INSURANCE BINDER

Effective Date and Hour__________________________

Insured__________________________________________

Address__________________________________________

Company__________________________________________

Premium__________________________________________
       __________________________________________

Coverage___________________________________________________
        ___________________________________________________
        ___________________________________________________
        ___________________________________________________

This binder is evidence that ___________________________has
placed the described insurance with the above Company for
the amount set forth.  This binder shall remain in force
for ____days from the date of commencement of liability
hereunder or when, if earlier, it is replaced by a policy
of the Company, and is subject to all the terms and
conditions of said policy as customarily issued by the
Company.  This binder may be cancelled by the Insured by
mailing to the Company written notice stating when
thereafter such cancellation shall be effective.  This
binder may be cancelled by the Company by mailing to the
named insured at the address shown in this binder written
notice stating when not less than ten days hereafter such
cancellation shall be effective.

                          _______________________________

                          By_____________________________

                          Dated__________________________

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