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Office of the Commissioner of Insurance FORM CIS 005 Page 1 of 5
Commonwealth of Puerto Rico
P.O. Box 8330
San Juan, Puerto Rico 00910-8330
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
1. International Insurer’s Name: __________________________________________
2.Affiant’s Full Name (Initials are Not Acceptable): _________________________
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