Ncci Officer Exclusion Form

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Forms Manual of Workers Compensation and Employers

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7 hours ago The Forms Manual is an indexed compilation of workers compensation policy forms and endorsements. It includes general endorsements and state-specific endorsements. It also contains endorsement notes that clarify when and how to use specific forms and endorsements.

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New Mexico Officer Exclusion V3

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1 hours ago WORKERS’ COMPENSATION ADMINISTRATION NEW MEXICO EXECUTIVE EMPLOYEE AFFIRMATIVE ELECTION FORM I, _____, am a “worker”as defined in the New Mexico Workers’ NAME Compensation Act, §52-1-1, et seq. or the New Mexico Occupational Disease Disablement Law, §52-3-1, et seq. (the Acts).

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GEORGIA STATE BOARD OF WORKERS' COMPENSATION

GEORGIA Sbwc.georgia.gov Show details

5 hours ago business address (month) (year) a copy of this form must be filed with your current workers' compensation carrier. if you do not have a carrier, and the business has 3 to 5 corporate officers or limited liability members and no employees, this form must be filed with the state board of workers' compensation at 270 peachtree street, n.w., atlanta, georgia 30303 -1299.

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NOTICE FOR WORKER’S COMPENSATION AND …

NOTICE Forms.in.gov Show details

2 hours ago STATEMENT OF VOLUNTARY EXCLUSION (IC 22-3-6-1 (b)(1) / IC 22-3-7-9 (b)(9)) An officer of a corporation may not be considered to be excluded as an employee under IC 22-3-2 through IC 22-3-6 until the notice is received by the insurance carrier and the board.

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Workers' Compensation Exclusions

NOTICE Workerscompensationshop.com Show details

1 hours ago Workers’ Comp Exemption Forms Some of the states listed above require owners and officers to sign and file specific state inclusion or exclusion forms depending on how the business is organized. Many states refer to these forms as Notice of Election to be Exempt from Workers' Compensation Insurance.

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Workers' Compensation Insurance Forms North Carolina

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7 hours ago Workers' compensation insurance is required by law for North Carolina employers. North Carolina forms and applications such as owners inclusion or exclusion forms are sometimes updated by the state. Contact us if you need help or can't find the workers' compensation form your need for North Carolina.

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State of Connecticut Workers’ Compensation Commission

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1 hours ago Officer of a Corporation or a Member of an LLC _____ DO NOT SEND THIS FORM TO A DISTRICT OFFICE! Send to: WORKERS’ COMPENSATION COMMISSION 21 OAK STREET, 4th FLOOR HARTFORD, CT 06106 Pursuant to C.G.S. Section 31-321, this notice must be served upon the Workers’ Compensation Commission in person OR by registered or certified mail.

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Exemption Form Florida Workers Compensation Insurance

Exemption Floridawc.com Show details

9 hours ago "The collection of the social security number on this form is specifically authorized by Section 440.05(3), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have applied for and/or been issued a Certificate of Election To Be Exempt.

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National Council on Compensation Insurance (NCCI)

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Just Now 2021 NCCI Individual Risk Rating Working Group Meeting. Nov. 2, 2021. Virtual. The NCCI Individual Risk Rating Working Group (IRRWG) is a working group of the NCCI Actuarial Committee. Its primary focus is on the research and review of NCCI's experience rating and retrospective rating plans. View Events and Programs.

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Forms 509 and 513 Department of Labor & Industry

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Just Now Form 509 and Form 513. 509. Application for Executive Officer's Declaration - OCR. LIBC-509. 513. Executive Officer's Declaration - OCR. LIBC-513.

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Inclusion/Exclusion Forms – AmeriTrust Online

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3 hours ago MD – C-15R – MD Inclusion Form – Sole Proprietors and Partners Election Form; MD – C-16R – MD Exclusion Form; Massachusetts. MA – Form 153 – MA Affidavit of Exemption for certain Corporate Officers or Directors; Michigan. MI – 171 – MI Application for Exclusion of Executive Officers of a Corporation or Members-Managers or an LLC

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IC16 Exclusion Form version 092018

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4 hours ago WORKERS’ COMPENSATION COMMISSION EXCLUSION FORM 10 East Baltimore Street Baltimore, Maryland 21202-1641 Form IC-16 (09/2019) INSTRUCTIONS: Pursuant to Labor & Employment Article §9-206, Annotated Code of Maryland, officers or members of certain business entities may elect to be exempt fomr workers' compensation

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CORPORATE OFFICER NOTICE TO REJECT

CORPORATE Wcc.sc.gov Show details

1 hours ago This form may be used when an officer desires to become exempt from the provisions of the South Carolina Workers’ Compensation Act. For additional information regarding the provision of Section 42-1-520 and this form, contact your insurance carrier or the South Carolina Workers’ Compensation Commission, Coverage Division, Post Office Box 1715,

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Endorsements / Policy Forms Workers Compensation NCRB

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1 hours ago For questions regarding form filings, use this document as a reference guide: WC Form Proposal Guidelines and FAQs. Form Number Description; WC 00 00 00C: Workers Compensation and Employers Liability Policy: Partners, Officers and Others Exclusion Endorsement: WC 00 03 09B

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Forms Arkansas Workers' Compensation Commission

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8 hours ago Forms & Claims Assistance The Arkansas Workers' Compensation Commission's forms and other claims adjusting items are available for downloading or printing on the links below. A list of contacts for questions regarding the filing or completion of the various claim forms can be found via this link - …

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State of New York WORKERS' COMPENSATION BOARD

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2 hours ago executive officer of such corporation named in the notice from coverage of this chapter. Such election shall be filed with the insurance carrier or the chair in the case of self-insurance upon a form prescribed by the chair of the workers' compensation board. Such election shall be effective with

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(WC14/15) EMPLOYERS NOTICE TO EXCLUDE OR INCLUDE …

EMPLOYERS Cluettinsurance.net Show details

1 hours ago officer of a corporation may elect annually to be exempt from coverage by filing written certification of the election with the department and the employer’s insurance carrier. ( ) I, _____ choose to be excluded from my (PRINT FULL NAME) employer’s workers’ compensation insurance policy.

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Tennessee Bureau of Workers’ Compensation 220 French

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2 hours ago FORM I-6 NOTICE OF CORPORATE OFFICER TO EMPLOYER OF ELECTION NOT TO ACCEPT PROVISIONS OF WORKERS’ COMPENSATION ACT OF TENNESSEE This form is to be used when an officer of a corporation elects to be exempt from the provisions of, and not be covered by, the Tennessee Workers’ Compensation Act. This election shall not become effective until 30

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Request an exemption from workers’ compensation coverage

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3 hours ago Corporate officers who own at least 25% interest in the corporation can file a Form 153 - Affidavit for Certain Corporate Officers or Directors with the Department of Industrial Accidents (DIA) to request an exemption from workers compensation coverage. All eligible corporate officers must sign the Form 153, to exempt themselves

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FORM 153 The Commonwealth of Massachusetts DIA Use …

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6 hours ago of the Massachusetts Workers’ Compensation Act (M.G.L. c. 152). • If the corporation named on this form employs no persons other than the eligible corporate officer(s) or director(s) who have exercised their right of exemption by signing the Form 153, said corporation may legally operate without workers’ compensation coverage.

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Workers' Compensation Compliance

FORM Dli.pa.gov Show details

9 hours ago To request exclusion of permissible executive officers from the provisions of the Workers' Compensation Act, complete and file an "Application for Executive Officer Exception," form LIBC-509, concurrently with the appropriate number of properly executed "Executive Officer's Declarations," form

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Employee Rejection of Terms Form Industrial Commission

Employee Azica.gov Show details

8 hours ago See A.R.S. § 23-906 (B)- (C). To be valid, the Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law must be filled out in duplicate (i.e., two times) and must be filed with the employer prior to the employee sustaining workplace injuries. The employer must, in all cases, file a copy of the Employee’s Notice of

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Rejection of Coverage (Form 16A) Virginia Workers

Rejection Workcomp.virginia.gov Show details

804-418-49173 hours ago Email address of Employer and Officer for E-signature. This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax to 804-418-4917. For questions concerning the Rejection of Coverage form please call the Insurance Department of the Commission at (804) 205-3586 or email vwcinsurance

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ELECTION OR REJECTION OF COVERAGE FOR SOLE …

ELECTION Alicunderwriters.com Show details

5 hours ago CORPORATE OFFICERS Note: ** Sole proprietors, partners and members of LLC’s are excluded from the North Carolina workers’ compensation laws and benefits unless coverage is elected in writing. ** Executive Officers of a Corporation a re covered under the North Carolina workers’

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Owner and Officer Exclusions in Workers’ Compensation

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3 hours ago Owner inclusion and exclusion rules will vary by state – many states require owners and officers to sign and file specific workers’ compensation state inclusion or exclusion forms, depending on how the business is organized. State Specific Rules

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Forms Workers' Compensation Commission

Forms Wcc.sc.gov Show details

3 hours ago Forms The South Carolina Workers' Compensation Commission offers all of its forms in PDF fillable format, or that they can be printed out and completed manually. Please …

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Forms State Board of Workers' Compensation

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(404) 656-38703 hours ago Forms. Georgia State Board of Workers’ Compensation provides all forms, upon request, free of charge. To request copies of forms, please call (404) 656-3870. Do not send any additional copies of any forms when filing in paper. STAMPED COPIES WILL NOT BE RETURNED.

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Application To Exclude Corporate Officers or LLC Members

Exclude Labor.vermont.gov Show details

8 hours ago Form 29 – Rev. 2/13. Application To Exclude Corporate Officers or LLC Members From Workers’ Compensation Coverage Officer/Member Exclusion. Vermont law permits corporate officers or LLC members to exclude up to four (4) officers or members from protection under the Vermont Workers’ Compensation Act.

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N.C. Industrial Commission Forms

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919-715-02822 hours ago If the claim meets one of the two exceptions listed above, the Form 19 may be downloaded, printed, filled out, and mailed into the N.C. Industrial Commission, faxed to the N.C. Industrial Commission at 919-715-0282, or e-mailed to forms@ic.nc.gov. Please note that if the claim does not meet one of the exceptions outlined above, the Form 19 will

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WC337 (12/15) Notice of Exclusion State of Michigan

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517-284-89225 hours ago WC-337 (12/15) Notice of Exclusion. This form is used to exclude certain individuals from insurance coverage as permitted by statute and is not available online. To find out whether you qualify for this exclusion and obtain a copy of the form, contact the Compliance & Employer Records Division at 517-284-8922. A Notice of Exclusion (WC-337), is

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Corporate Officer Exclusion Request Oregon

Corporate Oregon.gov Show details

471-031-00179 hours ago Oregon Administrative Rule 471-031-0017 Corporate Officer/Director Election (1) For the purposes of ORS 657.044, the term "substantial ownership" means each corporate officer owns at least ten percent of the corporation and the total ownership of the corporation among those officers being excluded is at least seventy-five percent.

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Exemptions myfloridacfo.com

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8 hours ago Exemptions. The purpose of filing an exemption is for an officer of a corporation or member of a limited liability company to exclude themselves from the workers' compensation laws. Upon issuance of a Certificate of Election to be Exempt, the officer or member is not an employee and may not recover workers' compensation benefits.

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Division of Workers' Compensation (DWC) forms and notices

Division Tdi.texas.gov Show details

3 hours ago Division of Workers' Compensation (DWC) forms and notices. Alternate forms. DWC has a form developer kit for stakeholders who develop their own forms. Before using these items, please read the Readme file included. Alternate forms must use DWC specifications and be approved for use by DWC.

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Forms Labor Cabinet

Forms Labor.ky.gov Show details

Just Now Application for Resolution of a Claim - Occupational Disease [ docx, 111KB] Workers' Comp / Workers' Claims / Forms. Application for Resolution-Interloctory Relief [ pdf, 135KB] Workers' Comp / Workers' Claims / Forms. Application for Split Coverage or Wrap Up (Form 375) [ pdf, 415KB] Workers' Comp / Compliance / Forms.

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Forms & Documents Louisiana Workers' Compensation

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6 hours ago LWCC is Louisiana's largest workers' compensation carrier, providing coverage to approximately 20,000 policyholders. We are a private, nonprofit mutual insurance company that revitalized a workers' comp system on the verge of collapse and have continued to provide much-needed stability in Louisiana. LWCC carries an "A" (Excellent) rating from A.M. Best.

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Online Forms wcc.state.ct.us

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1 hours ago The Form 6B “COVERAGE ELECTION BY EMPLOYEE WHO IS AN OFFICER OF A CORPORATION OR A MANAGER OF AN LLC” is to be completed by an Officer of a Corporation or a Manager of a Limited Liability Company (LLC) who wishes to be excluded from workers’ compensation insurance coverage.

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Executive Officers and Partners WCIRB California

Executive Wcirb.com Show details

9 hours ago Effective July 1, 2018, the individuals who may elect to exclude themselves from coverage if they meet the requirements for exclusion include: a qualifying officer or member of the board of directors of a quasi-public or private corporation who owns at least 10% of the issued and outstanding stock of the corporation, or at least 1% of the

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Officers, Owners and Partners KEMI

Owners Kemi.com Show details

8 hours ago Officers, Sole Proprietors, Partners, and Members of LLCs. Under Kentucky law, corporate officers are automatically covered under the Workers’ Compensation Act of Kentucky, unless they elect not to be covered. If an officer elects to be excluded from the Workers’ Compensation Act, KEMI requires a signed and stamped copy of the filed Form 4

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Workers' Comp Forms TN.gov

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615-532-48122 hours ago If you have additional questions, please call 615-532-4812 or 800-332-2667 or contact us by email at wc[email protected]tn.gov. Find out about other available assistance programs by contacting an ombudsman .

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Corporate Officer Exclusion Form www.iowaworkcomp.gov

Corporate Iowaworkcomp.gov Show details

1 hours ago Corporate Officer Exclusion Form. File: 14-0061corpofficerex.pdf. IowaWorkforceDevelopment.gov; Website Feedback The Iowa Division of Workers’ Compensation (DWC) is the state government entity charged with educating the public about Iowa’s workers’ compensation system. This website is provided for informational purposes only. Nothing

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SPECIFIC PERSON EXCLUSION FORM

SPECIFIC Ezworkerscomp.com Show details

1 hours ago Executive Officers may elect exclusion if the corporation has ten or fewer stockholders and the executive officer owns at least 10% of the stock. A corporate board resolution authorizing exclusion is to be executed. (Certified Resolution/Consent Form must also be completed.) Limited Liability Company

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North Sound BHASO Compliance Plan nsbhaso.org

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8 hours ago Federal Compliance Officer. An employee of HCA, who serves as its Federal Compliance Officer and operates its fraud and abuse telephone hotline. Office of Inspec tor General (OIG) Exclusion Program. A Federal program and database that identifies the OIG Exclusion Program called the List of Excluded

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Forms Industrial Commission of Arizona

Forms Azica.gov Show details

7 hours ago Interactive forms may be opened online or downloaded to your PC and completed at a later time when offline. Interactive forms enable the user to enter information directly into the forms. Forms which require a signature or other type of manual authentication need to be printed, signed or authenticated, then transmitted to this office.

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WORKERS COMPENSATION ELECTION / REJECTION FORM

WORKERS Support.ameritrustgroup.com Show details

1 hours ago The undersigned officers of the Corporation named above stipulate that meeting requirements as set forth by the rules promulgated by the State shown in the …

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Commonwealth of Virginia Workers’ Compensation Commission

Virginia Workcomp.virginia.gov Show details

6 hours ago accident under the Virginia Workers’ Compensation Act. Notice needs to be provided to the employer and a copy must be filed with the Virginia Workers’ Compensation Commission, 333 East Franklin Street, Richmond, VA 23219. A Rejection of Coverage is continuous unless a Termination of Prior Officer Rejection of Coverage (form 17A) is filed.

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What is criminal trespass? Degree? Seattle.gov Home

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7 hours ago Park Ranger and Police Officer Exclusions: If the conduct that results in a trespass warning creates a significant risk of personal injury or property damage, the person may be removed and excluded from the park for the remainder of the day. If the conduct includes a felony or …

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Forms Workers' Compensation Division NH Department of

Forms Nh.gov Show details

7 hours ago NH Workers' Compensation Task Analysis (23-b WC, 9-2015) Lump Sum Settlement Forms (15 WCA, 10-1999) Release and Settlement of Claim (WC-3PR-1, 6-2015) Authorization for Compensation for Death (14WCA, 10-2001) Authorization to Permit Witness at Medical Examination (38 WCA, 9-2015)

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Workers' Compensation

Forms Wvinsurance.gov Show details

8 hours ago The West Virginia workers’ compensation market has over 300 carriers offering workers’ compensation insurance to West Virginia employers. Since the workers’ compensation privatization legislation went into effect in 2006, the aggregate loss costs have decreased more than 78%.

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Frequently Asked Questions

What are the exclusion forms for workers comp?

GA – 171 – GA Notice of Election or Rejection of Workers Compensation Coverage IA – 14-0061 – IA Corporate Officer Exclusion from Workers Compensation or Employers Liability Coverage KS – 171 – KS Election of Individual, Partner, Member of an LLC or Self-Employed Individual

When to request exclusion of an executive officer?

A subchapter C for-profit corporation may request exclusion of its executive officers if they have at least a 5% interest in the corporation.

How to obtain a notice of exclusion form?

To find out whether you qualify for this exclusion and obtain a copy of the form, contact the Compliance & Employer Records Division at 517-284-8922. A Notice of Exclusion (WC-337), is not considered valid unless stamped by this Agency showing it is on file.

Who is not an affiliate of NCCI insurance?

Non-Affiliate Pricing—A customer of NCCI that is not licensed and/or writing workers compensation in a state where NCCI is the licensed rating and/or statistical organization.

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