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ACORD 3 (2011/07) Page 2 of 4 REPORTED BY REPORTED TO REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

HUD-CPL0003 (03/07) - 3 - New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing

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