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O??8?*ۤ\??=??q"?|?B?2b-??}?cm????IEND?B`?3 ??? ?@@? ?? ??OtherYesNoPolicy NumberCarrier$Is there a swimming pool on premise?XDoes the pool(s) have a secure 4ft no climb fence with self latching lock on the inside?Is there a diving board?/Is the pool used by anyone other the applicant? Dude Ranch0Entertainment/Amusements involving farm animals?Are dogs owned? How many?Breed0Any past aggressive behavior? (I.e. bites, etc,)LineProperty LiabilityAutoUmbrellaPremiumDAre independent contractors hired to perform any farming operations? Type of use? How is animal waste disposed of?$Is there an airstrip on the premise?Open Range Area?City: Year BuiltTypeBasicBroad DescriptionLimit of InsuranceComputer CoverageCentral StationLightning RodsOther (explain)Age:If yes, explain:(If yes, at which location and structure?=Is the applicant involved in any of the following activities? Pony RidesPublic Horse Rentals=Hunting or fishing on premises by other than owner and family3Motorcycles, ATV's operated by other than applicantExplain any "Yes" answers:If yes, what are the receipts?DWELLING COVERAGE FORMCounty:State:Zip: Location #Main DwellingOther Dwelling$# of Families Square FeetType of ConstructionAgeHeating: Smoke Alarm Fire AlarmFire ExtinguishersRenovation Update:Protection ClassRoof:FARM STRUCTURES COVERAGE FORMSCHEDULED PERSONAL PROPERTYFARM PERSONAL PROPERTYClass I HardwareClass II Software0Limits of Insurance - Occurrence/Aggregate (000) $300/$600 $500/$1,000$1,000/$2,0008Do you wish liability coverage for any owned watercraft?@Operator information (names, dates of birth, drivers license #).+Equine Underwriting and Safety Information: Experience:-Is there 24 hour supervision of the facility?%Are emergency numbers clearly posted?@Are State Equine Liability signs clearly posted (if applicable)?Do you participate in parades?If yes, please provide details:$Are Non-boarders using the facility?If yes, please explain: Horse ShowsDates of Shows:Types of Shows:#Do you have stall rental for shows?(Do you have an EMT present at all shows?Are shows sanctioned?If yes, by whom?%Do you have bleachers or grandstands?If yes, what is the height?%If yes, what is the seating capacity?If yes, number of hookups?.Do you provide concessions during these shows?7Do you have vendors on the premises during these shows?&If yes, please explain the items sold:>Do you lease your facility to others to hold shows and events?,Do you require proof of liability insurance?Do you teach:EnglishIndependent InstructorEmployeeTWhat is the number of students per week given lessons by the Independent Instructor?Are you a certified instructor?WDescribe your employee's and/or Independent Instructor's experience and qualifications:,Describe your experience and qualifications:LDo you obtain a certificate of insurance from the Independent Instructor(s)?If yes, number of shows?What are the gross receipts?(What is the minimum age of the students?Clinics"If yes, who teaches these clinics?Type of Clinics:Number of Clinics:&What are the receipts for the clinics? Day Camps.Do you provide riding facilities for boarders?3Do you have boarders sign hold harmless agreements?If yes, provide copy./Number of stalls on premises used for boarding?#Maximum number of animals pastured?$Annual Receipts related to Boarding?Boarding Payroll?!Sales on Premises Operated by YouWhat are the annual receipts?Do you cut or bale hay?$Do you prepare or mix feed for sale?$Do you sell horses on your premises?How many do you sell a year?CWhat is the method of sale (private treaty, auction, consignments)?(Do you sell food or operate a snack bar?!Do you sell tack and/or clothing?NewUsed0Do you offer repair of tack or riding equipment?)If yes, what is the location of the shop?2Are dogs contained when customers are on premises?Policy PeriodDescription of Claim/OccurrenceAmount Open/ClosedExplain yes answers:1Do you ask for proof of liability insurance (COI)How is it used and by whom?%What does the Independent do for you?Make, Model VIN?)Is temporary overnight boarding provided?JIs any part of the premises used or leased for organized recreational use?If yes, explain.Polo/Horse BallJAre you named as Additional Insured on the Independent's liability policy?Qor beverage service, animal boarding, sale of Christmas trees, or any other uses?Are the farm premises open to the public as roadside stands, "uPick," recreational, "rent a garden," auction, sales, show, foodExplain:,(if yes attach Acord Watercraft Application)UIs there any land held for real estate development or speculation? If yes, provide details:If yes, explainNSEW4PREMISES DIAGRAM (Please complete for each location)!INSURANCE FRAUD WARNING STATEMENT=thereto commits a fraudulent insurance act, which is a crime.TAny person who knowingly presents a false or fraudulent claim for payment of a loss Ror benefit or knowingly presents false information in an application for insuranceKis guilty of a crime and may be subject to fines and confinement in prison.XIt is unlawful to knowingly provide false, incomplete or misleading facts or informationSto an insurance company for the purpose of defrauding or attempting to defraud the Scompany. Penalties may include imprisonment, fines, denial of insurance, and civilNdamages. Any insurance company or agent of an insurance company who knowinglyTprovides false, incomplete, or misleading facts or information to a policyholder or Tclaimant with regard to a settlement or award payable from insurance proceeds shall Ube reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.DelawareTAny person who knowingly, and with intent to injure, defraud or deceive any insurer,is guilty of a felony.FloridaSAny person who knowingly and with intent to injure, defraud, or deceive any insurerAmisleading information is guilty of a felony of the third degree.IdahoOAny person who knowingly, and with intents to defraud or deceive any insurance Ucompany, files a statement containing any false, incomplete or misleading informationIndianaRclaim containing any false, incomplete or misleading information commits a felony.MAny person who knowingly and with intent to defraud any insurance company or Sother person files a statement of claim containing materially false information or %the attach application to your agent.hWarning Statement for the State in which your application is being made before executing and submitting iThis statement is provided to you with the insurance application. READ and initial the applicable Fraud ArizonaXFor your protection, Arizona law requires the following statement to appear on this formSAny person who knowingly presents a false or fraudulent claim for payment of a loss+is subject to criminal and civil penalties. CaliforniaVAny person who knowingly presents a false or fraudulent claim for payment of a loss isNguilty of a crime and may be subject to fines and confinement in state prison. LouisianaVAny person who knowingly presents a false or fraudulent claim for payment of a loss orYbenefit or knowingly presents false information in an application for insurance is guilty@of a crime and maybe subject to fines and confinement in prison.MaineUIt is a crime to knowingly provide false, incomplete or misleading information to an Linsurance company for the purpose of defrauding the company. Penalties may >include imprisonment, fines or a denial of insurance benefits. MinnesotaUA person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.New HampshireKAny person who, with a purpose to injure, defraud or deceive any insurance Hcompany, files a statement of claim containing any false, incomplete or < Mmisleading information is subject to prosecution and punishment for insurance New JerseyLAny person who knowingly files a statement of claim containing any false or Bmisleading information is subject to criminal and civil penalties. New Mexico7ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT<CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS?FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF @A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIESNew YorkNAny person who knowingly and with intents to defraud any insurance company or Uother person files an application for insurance or statement of claim containing any Umaterially false information, or conceals for the purpose of misleading, information Sconcerning any fact material thereto, commits a fraudulent insurance act, which is Wcrime, and shall also be subject to a civil penalty not to exceed five thousand dollars:and the stated value of the claim for each such violation.OhioOklahomaQWARNING: Any person who knowingly, and with intent to injure, defraud or deceiveFany false, incomplete or misleading information is guilty of a felony. PennsylvaniaIAny person who knowingly and with intent to defraud any insurance companySor other person files an application for insurance or statement of claim containingWany materially false information or conceals for the purpose of misleading, informationRconcerning any fact material thereto commits a fraudulent insurance act, which is Aa crime and subjects such person to criminal and civil penalties.Virginia5imprisonment, fines and denial of insurance benefits.kThe statements given in this application are true and accurate. This includes the limits of insurance and concerning this application.Applicant's Signature:Date:Agent's Signature: License #:Tinformation is subject to prosecution and punishment for insurance fraud as providedfraud, as provided in RSA638:20ZAny person who, with intent to defraud or knowing that he is facilitating a fraud against San insurer, submits an application or files a claim containing a false or deceptive'statement is guilty of insurance fraud.Oany insurer, makes any claim for the proceeds of an insurance policy containingOinsurance company for the purpose of defrauding the company. Penalties includejloss history as shown. I have not willfully concealed or misrepresented any material fact or circumstanceRFor your protection, California law requires the following to appear on this form:Vfiles a statement of claim containing any false, incomplete or misleading information Sfiles a statement of claim or any application containing any false, incomplete, or KentuckyRconceals, for the purpose of misleading, information concerning any fact material StructureMortgagee NameMortgagee Address Loss Payees:Item DescriptionLoss Payee NameLoss Payee Address What is the depth of the pool? 5Are dogs allowed in barn/horse areas? If so, describe7Does Applicant prepare and/or sell animal feed? Central Air ConditioningNWhat is the number of students per week given lessons by you or your employee?ZWhat are the annual gross receipts derived from instruction by the Independent Instructor?BDo you secure releases/hold harmless agreements from all entrants?!If yes, what is the construction?@Description (include year, make, model, serial #, name of horse)Vaulting?Are there any unusual hazards on the premises such as (but not limited to) dump pits, silage pits, sump holes, lakes reservoirs? Replacement Cost/Contents?Do you collect proof of liability insurance from these vendors?>Do you serve on any Corporate or other Board for remuneration?IF ATV, how many wheels?What is the value of each?Distance from Fire HydrantLocal,Sprinkler System/Certificate/Maint. Contract]Do you have all clients sign a hold harmless agreement and is it kept in file and maintained?eApplicant must be named as Additional Insured. Please provide a copy of the Certificate of Insurance:Do you rent/lease your facility to others to hold clinics?"Is the buyer allowed to test ride?Reconditioned Tack,ADDITIONAL COMMENTS/UNDERWRITING INFORMATIONMiles from Fire Department?ACVpage 2page 3page 4page 6page 7page 8page 9@Is there a home on your farm premises that is insured elsewhere?(If yes, Carrier, Policy # & policy term:Loss Settlement Building:YDo you lease any part of the building or land to someone else (other than your boarders)?ADo you lease any part of the buildings or land from someone else?What are the Receipts?Additional Insured AddressHay/Carriage/Sleigh RidesIDo you wish liability coverage for any owned snowmobiles/ATVs/Golf Carts?Are any licensed for road use?"Do you want off premises coverage?How are they used?Detail(Are you a subsidiary of another company?!5 YEAR PRIOR COVERAGE INFORMATION5 Year Loss History DateHas any policy been canceled? Non-renewed? Declined?Number of Claims(not applicable in MO)SPlease use a separate coverage form for each location with dwellings to be insured.Street: Deductible:$500$1,000$2,500Name of Responding Fire Dept.UIs there another water source(pool, lake, etc), if so, what and distance to dwelling? # of AcresBldg # on DiagramIs this your primary residence%Is this a secondary residence for you&Is the dwelling within the city limitsB. Appurtenant StructuresC. Household ContentsD. Loss of UseCovered Cause of LossEarthquake CoverageWho occupies the dwellingHeat: Type of Heat%Wood Stove, if yes need questionnaireBurglar Alarm:(attach certificate)Year of update needed for bldgsover 20 yearsMobile or Modular Building_Asphalt/Fiberglass, Metal, Tile, Cedar. Loss Settlement: RC= Replacement Cost, ACV= Actual CashYESNOSpecialSpecial Dwlg/Broad ContentsRCERCOwnerTenantCaretaker/employeeYear:Wiring:Location 911 address Occupancy Full Time or Part Time Plumbing:A. Dwelling Limit of InsurancecType of Construction: Frame, Masonry, Steel Frame, Pole, Mobile Home/Mobile Building. Type of Roof:)Therapeutic or Riding for the HandicappedUIs there another water source(pool, lake, etc), if so, what and distance to building?%Are there living quarters in the barnIs there an office in the barnUPlease use a separate coverage form for additional farm structures & other locations.Description/Use+What is the description/use of the building#Height/# of stories/# of open sides$Location of Heat in bldg(office,etc)Hay storage less than 50 bales%Is smoking prohibited and sign postedMobile building/Are you insuring all buildings at all locationswType of Construction: Frame, Masonry, Steel Frame, Pole, Mobile Home/Mobile Building. Type of Roof: Asphalt/Fiberglass,]Metal, Tile, Cedar. Loss Settlement: RC= Replacement Cost, ACV= Actual Cash Value?Schedule all items with complete description. An appraisal or sales receipt less than 5 years old must accompany application for all items $5,000 and over per item.6* RC is available for scheduled tack, office contents.Other:Covered Causes of Loss: Earthquakel(indicate the # to be insured and limit per animal), Horses by name. Livestock $5,000 per limit per animal.(RC)*RBlanket Farm Personal Property 90% Coinsurance Applies - Attach Inventory/SchedulegIrrigation Equipment, Poultry, Tobacco, Cotton, Milk Tanks, Milking Equipment, Portable Buildings, etc.bare excluded property under Coverage F and must be scheduled under Coverage E. Refer to Coverage F!Form for other excluded property.7MORTGAGEES, LOSS PAYEES AND ADDITIONAL INSURED SCHEDULE MORTGAGEES:Additional Insured Name:Reason/Relationship to InsuredjUnless Specifically Endorsed Non-Owned Horses In Your Care, Custody or Control Are Not Covered For Injury or Death.$100/200(Are you the primary manager of facility?If no, who is the manager:Explain Supervision:Please provide a copy.< $Are no smoking signs clearly posted?N/AMDo any Associations, Pony Clubs, 4-H, Girl/Boy Scouts, etc use your facility?6Enclose sample copies of all hold harmless agreements.)Are client's dogs allowed on the facilityIf yes, are leashes required?"All fence/gates in good condition?5How often is fencing checked (daily, weekly, monthly,never)?'What type of perimeter fencing is used?&Do you lease horses to or from others?Need copy of ContractDetails: What breeds?8If buyer is allowed to test ride, required to have Hold ?Harmless signed and proper footwear and headgear worn if minor.GIf buyer is allowed to test ride, is the level of experience evaluated?0What is sold (hamburgers, hot dogs, chips etc.)? Deep Fryer?$If so, what are the annual receipts?5Do you/employee perform any type of farrier services?Not Applicable0Do you sponsor any horse shows on your premises?Off Premises?Total per showReceipts per show?"Number of spectators per day/show?$Number of participants per day/show?If yes, what are the Receipts?Number of stalls available?&Are they Temporary or Portable Stalls?Attach sample copy7Do you provide RV or camper hookups during these shows?/What are the receipts for leasing the facility?Riding InstructionsWesternJumping2Pony Club Activities and Vaulting refer to CompanyIs instruction provided by:YoudIf instruction is provided on your premises by an Independent Instructor, how many such instructors?9Is your employee and/or Independent Instructor certified?By whom:\What is the maximum number of students per instructor per lesson for you and your employees?`What is the maximum number of students per instructor per lesson for the Independent Instructor?UWhat are the annual gross receipts derived from instruction by you and your employee?Number of days per clinicAverage Attendance:Details?@Do you require outside clinicians to provide proof of insurance?Please send copy>Do you hold/sponsor clinics for non-students on your premises?Off Premises:"If yes, complete Camp SupplementalBoarding (not your own horses)If yes describe:$If boarding self-board or full care?If no, explain:"Maximum number of animals boarded?mList following if you wish to schedule: Machinery, Equipment, Tack, Irrigation/Pumps, Hay/Grain/Feed, Cattle Additional Insured:CAttach Care, Custody and Control Application if coverage is wanted.1Are Safety and Barn rules posted at the facility?Has any animal ever escaped?XIf yes, provide Certificate of Insurance with the Applicant named as Additional Insured.page 5?Show all buildings on the premises (whether insured or not) and distance in feet between them. Label all buildings the same as the appliation and photos and attach a dated photograph of every building (indicate NC if not covered)Equine Farm & Ranch ApplicationCompany Use OnlyCustomer No. Producer Nob(Note: This is not a Binder. Incomplete or unsigned applications will be returned for completion.),Agency's Name and address (Include Zip Code)Agency Phone #()-City StZip Producer # Transaction New BusinessQuoteIssueEffective DateQuote Desired By Renewal of # to Agency BillAnnualSemi-A QuarterlyChoice/Direct Bill to Applicant Mortgagee Applicant isOwner/OperatorAbsentee OwnerManager Does Owner: Own PropertyLease PropertyLLC Partnership Corporation;Applicant - Name and address ( include County and Zip Code) Applicant:Applicant's Farm Business NameCityCountyStateApplicant's Phone Number:Website/www. FEIN #*Person to contact for inspection purposes:Name:Phone :4IS THIS APPLICANT DIRECT TO YOUR AGENCY OR BROKERED?General Underwriting Questions#How long has agent known applicant?/Provide the date when agent inspected premises:2Are horse operations your main source of income? If not, what is?>Are you engaged in any other business, profession or Trade? If yes, describe.:Describe your horse operationsaHow many years experience/in the business with horses? If none, any experience as Farm Mgr, etc.-What primary breed of horse do you work with?5Are there any farm/ranch operations other than horse?If yes, what?-Do you perform any custom farming operations?*Describe the type of custom farming you doNumber of farm/ranch employeesNumber of domestic employees!Is Worker's Compensation carried?If yes, Name of Company:Policy Number:Effective Date:Expiration Date:=Are there any non-farm/ranch operations conducted on premise?If yes, describe:Name of insurance provider[Is there a business or professional office (non-farm) in your dwelling or on your premises?JDo you own a non-farm residence in which you reside (I.e. vacation home)? 'Do you have liability insurance for it?-If yes, please provide insurance information:~Name of carrier: Policy number: Policy period:hIs the scheduled premises the only premises you own, rent or operate/maintain as a farm/ranch/residence?If no, explain./Do you own any (non-farm) rental dwelling(s)? (Do you wish liability coverage for them?!Is any property leased to others?Do you judge shows?What are your annual receipts?Policy Period:4Do you attend off-premises shows with your students?page 10&Fabric covered building/Brand/Warranty,Is there any urethane insulation in building(Fences inspected and repaired regularly?VEnter all claims or occurrences for the prior five years. Attach hard copy loss runs.*Loss Settlement Building ?Value, ERC=Extended Replacement Cost (*requires Cost Estimator))Building Class refer to Countrywide Rules5Inflation Guard applies to all structures if elected.4%Category (jewelry,etc)Do you hold day camps?ArkansasColorado6%TrainingWhat type of training is given?Do you have a trainer on staff?,If yes, what is the payroll for the trainer?AHow many lessons are considered part of their training agreement?Provide copy of agreement"Total payroll related to Training?OIf Trainer is independent contractor, do you require certificates of insurance?\Certificate of Insurance must name application as additional insured. Please attach a copy.'If racing, in which states do you race?Annual receipts for training?6What is the average number of horses trained per year? Owned Horses5How many horses do you own or lease for your own use?&How many are used for pleasure riding?How many are used for showing?How many are for sales prep?"How many are used for instruction?BreedingDo you manage stallions?If yes, how many?"How many are owned wholly by you?How many are owned by others?%What are your receipts from breeding?)What is your breeding operations payroll?!Do you manage or keep broodmares?How many broodmares do you own?GHow many non-owned broodmares do you have on your farm at any one time?Do you offer foaling services?$Do you have a veterinarian on staff?$(Professional Liability is excluded)LIABILITY SECTION double click for linkGTo add Drawing Tools - go to View, choose Toolbars, click Drawing box..If yes, provide COI for Professional LiabilityMailing Address @..\Camp Supplemental App\Camp Supplement excel for web final.xlsClick for additional page:#Click for Additional Dwelling Sheet:Are vet services provided for other than applicant horses?9RA person who knowingly and with intent to defraud an insurer files a statement of ?(ed 4/05) page 1 (ed 4/05)l(ed 4/05) page 11Z(ed 4/05) page 13Z(ed 4/05) pa<p ge 12 Additional Farm Structures FormsAdditional Dwellings SheetsGENERAL FRAUD STATEMENTBANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE @COMPANY OR ANTOHER PERSON FILES AN APPLICATION FOR INSURANCE OR CSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR ACONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYDFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS BA CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL]RCIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, VT OR WA; IN=DC, LA, ME, TN AND VA, insurance benefits may also be denied)IIN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, DOR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION KCONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS QUILTY OF A FELONY OF THE THIRD DEGREE.?IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO >KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR GANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMHCONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSEGOF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITSHA FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.HIN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR BMISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF JDEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIALOF INSURANCE BENEFITS.APPLICANT'S SIGNATUREDATE (MM/DD/YYYY)(10/08)COLORADO APPLICATION SUPPLEMENT.THIS NOTICE IS A PART OF YOUR APPLICATION FOR:FRAUD WARNINGJIt is unlawful to knowingly provide false, incomplete, or misleading factsGor information to an insurance company for the purpose of defrauding orGattempting to defraud the company. Penalties may include imprisonment,Hfines, denial of insurance, and civil damages. Any insurance company orGagent of an insurance company who knowingly provides false, incomplete,Jor misleading facts or information to a policy holder or claimant for the Dpurpose of defraduing or attempting to defraud the policy holder or Dclaimant with regard to a settlement or award payable from insuranceGproceeds shall be reported to the Colorado Division of Insurance within&the Department of Regulatory Agencies.DATE (MM/DD/YY)OHIO FRAUD STATEMENT6ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT=HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN<APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE'STATEMENT IS GUILTY OF INSURANCE FRAUD.^(10/08) Page 14] Page 15tRisks located in Florida: Do you want Sinkhole Loss Coverage to apply to your insured properties located in Florida?tRisks located in Florida: Do you want Sinkhole Loss coverage to apply to your insured properties located in Florida????? b??4???TT????k(???????s˨?ߩS?b?^ %?? ??) ??? ??5??qٲM?x޵Rv???|????ؾL??e??+?{l?? ?Y??5e????* w?? ^????1?????0I??d??A????G??*???\????$????????O????2?c>?o|??k??Z??T??_???? ?? @?q ??? ?E???$?U??! ?;???i?????????P???O??}??t?????????????| ? 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