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Michigan insurance business entity affiliate disclosure

Lara form fis 0200-2025

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The document is an Insurance Business Entity Affiliate Disclosure form used to add or remove Designated Responsible Licensed Producers (DRLP) and affiliates associated with an insurance business entity. It requires the disclosure of various relationships, identification details of the business entity, changes in address, and information about affiliates including any legal issues they may have faced. The form also includes sections for signatures and certifications regarding compliance with state insurance laws.

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