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Please list any additional dependents desiring coverage, including DOB, in the spaces below.
Please use the box below to list medical history including any diagnosis of medical conditions
that have occurred within the last 5 years and/or any on-going prescribed medications.
Please be certain to include insureds name if more than one person is wanting coverage.
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Capital Insurance Solutions Beaverton, OR
Fax : (503) 336-0836