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21.

Have you ever made any previous liability claims?

Yes

No

State the identity of all other insurance companies involved. State how they are related to this case.

22.

How many vehicles do you own? If none, do you live with relatives? If you do

live with relatives, state who they are. Do they own any vehicles? If so, please supply

any and all insurance policies relating to those vehicles.

Number of vehicles owned

Signature

Date

10

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