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Licensed Insurer Name :
Licensed Insurer FEIN :
Licensed Insurer NAIC :
 
Reconciliation Year : To
 
Amount of Direct Losses Paid :Range ($): 
Write-in Adjustment for Direct Losses :Range ($): 
Amount of Direct Loss Adjustment Expenses Paid :Range ($): 
Write-in Adjustment for Direct Loss Adjustment Expenses :Range ($): 
 
Date Submitted : To
Date Updated : To