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Workers' Compensation Revised Relativities

Notice of Carrier Intent - Certification Page 3

Notice of Carrier Intent Certification

I, ________________________________, am an officer of the ____________________________________ and in that capacity, I certify that all of the information contained in the Notice of Carrier Intent is complete, correct, and true to the best of my knowledge and belief.

_____________________________________

Officer´s Signature

_____________________________________

Officer´s Title

Attachment 4

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Last updated: 1/4/2018