Form U-111 I - Request For Inclusion Of Additional Interest Page 2

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NEW YORK STATE INSURANCE FUND
199 CHURCH STREET, NEW YORK, N.Y. 10007
INFORMATION REGARDING THE ENTITY FOR WHICH YOU HAVE REQUESTED COVERAGE
Policy Number
Entity Name
Nature of Business of this Entity
Location of this Entity
Number of Employees
Annual Payroll
$
Name of Executive Officer/Partner/Sole Proprietor
Home Address
Duties
Salary
$
Name of Executive Officer/Partner/Sole Proprietor
Home Address
Duties
Salary
$
Name of Executive Officer/Partner/Sole Proprietor
Home Address
Duties
Salary
$
Name of Executive Officer/Partner/Sole Proprietor
Home Address
Duties
Salary
$
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U-111A I
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