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** Insured:
** Policy #:
** Effective Date of Change:

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** Producer Name:
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SUBJECT TO ALL RULES AND PROCEDURES LISTED ON THE "ENDORSEMENT" PAGE (see when we need insured's signature)
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Connecticut FAIR Plan - 77 Hartland Street, Suite 308 - P.O. Box 280200 - East Hartford, CT 06128-0200
Telephone: (860) 528-9546 - Fax: (860) 282-0070
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