ACORD 187 (3/98)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 187 (3/98)
Professional Liability Supplement
ACORD 187, Professional Liability Supplement, is used to apply for
professional liability coverage for any of the following classes:
* Barbers and Beauticians
* Funeral Directors
* Optical and Hearing Aid Establishments
* Printers
* Veterinarians
This form is intended to be used as a supplement to the following forms:
* ACORD 126, Commercial General Liability Section
* ACORD 160, Business owners Application.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Producer
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext.)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION First Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Years In Business
Enter number: The number of years the insured has been in business.
IDENTIFICATION SECTION Nature Of Business
Enter text: The description of the nature/type of business.
IDENTIFICATION SECTION # of Employees - Full Time
Enter number: The number of full time employees.
IDENTIFICATION SECTION # of Employees - Part Time
Enter number: The number of part time employees.
IDENTIFICATION SECTION Annual Sales/Receipts
Enter amount: The total annual gross sales or receipts.
GENERAL INFORMATION
Are all employees licensed as
required by law? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are all
employees licensed as required by law?.
GENERAL INFORMATION
Are all employees licensed as
required by law? No
Check the box (if applicable): Indicates a No response to the question, Are all
employees licensed as required by law?.
GENERAL INFORMATION
Is applicant a member of a local or
national organization? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is applicant a
member of a local or national organization?.
GENERAL INFORMATION
If yes, provide name
Enter text: The name of the local or national organization the applicant is a member of.
GENERAL INFORMATION
Is applicant a member of a local or
national organization? No
Check the box (if applicable): Indicates a No response to the question, Is applicant a
member of a local or national organization?.
GENERAL INFORMATION
Do any employees work for others
in addition to the applicant? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do any
employees work for others in addition to the applicant?.
GENERAL INFORMATION
Do any employees work for others
in addition to the applicant? No
Check the box (if applicable): Indicates a No response to the question, Do any
employees work for others in addition to the applicant?.
FUNERAL DIRECTORS
INFORMATION
If funeral prepayment plans are
offered, are funds properly
audited, managed and distributed
by full-time director? Yes
Check the box (if applicable): Indicates a Yes response to the question, If funeral
prepayment plans are offered, are funds properly audited, managed and distributed by full-
time director?.
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Section Name
Field Name
Field and/or Section Description
FUNERAL DIRECTORS
INFORMATION
If funeral prepayment plans are
offered, are funds properly
audited, managed and distributed
by full-time director? No
Check the box (if applicable): Indicates a No response to the question, If funeral
prepayment plans are offered, are funds properly audited, managed and distributed by full-
time director?.
FUNERAL DIRECTORS
INFORMATION
Does applicant specialize in
cremation services? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
specialize in cremation services?.
FUNERAL DIRECTORS
INFORMATION
Does applicant specialize in
cremation services? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
specialize in cremation services?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are all prescriptions checked
against the original order when the
merchandise is delivered? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are all
prescriptions checked against the original order when the merchandise is delivered?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are all prescriptions checked
against the original order when the
merchandise is delivered? No
Check the box (if applicable): Indicates a No response to the question, Are all
prescriptions checked against the original order when the merchandise is delivered?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are records of all tests performed,
prescriptions filled and customer's
acceptance of merchandise kept
on computer or in a fire-resistant
cabinet? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are records of
all tests performed, prescriptions filled and customer's acceptance of merchandise kept
on computer or in a fire-resistant cabinet?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are records of all tests performed,
prescriptions filled and customer's
acceptance of merchandise kept
on computer or in a fire-resistant
cabinet? No
Check the box (if applicable): Indicates a No response to the question, Are records of
all tests performed, prescriptions filled and customer's acceptance of merchandise kept
on computer or in a fire-resistant cabinet?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are hearing aids or optical goods
manufactured or delivered only as
a result of a prescription from a
physician, audiologist or
optometrist? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are hearing
aids or optical goods manufactured or delivered only as a result of a prescription from a
physician, audiologist or optometrist?.
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Section Name
Field Name
Field and/or Section Description
OPTICAL AND HEARING
AID ESTABLISHMENTS
Are hearing aids or optical goods
manufactured or delivered only as
a result of a prescription from a
physician, audiologist or
optometrist? No
Check the box (if applicable): Indicates a No response to the question, Are hearing aids
or optical goods manufactured or delivered only as a result of a prescription from a
physician, audiologist or optometrist?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Does applicant employ
optometrists or opticians? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
employ optometrists or opticians?.
OPTICAL AND HEARING
AID ESTABLISHMENTS
Does applicant employ
optometrists or opticians? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
employ optometrists or opticians?.
PRINTERS
Are lottery, gaming or raffle tickets
printed? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are lottery,
gaming or raffle tickets printed?.
PRINTERS
Are lottery, gaming or raffle tickets
printed? No
Check the box (if applicable): Indicates a No response to the question, Are lottery,
gaming or raffle tickets printed?.
PRINTERS
Are food or drug labels printed?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Are food or
drug labels printed?.
PRINTERS
Are food or drug labels printed?
No
Check the box (if applicable): Indicates a No response to the question, Are food or drug
labels printed?.
PRINTERS
Are transportation, admission or
special event tickets printed? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are
transportation, admission or special event tickets printed?.
PRINTERS
Are transportation, admission or
special event tickets printed? No
Check the box (if applicable): Indicates a No response to the question, Are
transportation, admission or special event tickets printed?.
PRINTERS
Are money orders, securities, or
travelers checks printed? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are money
orders, securities, or travelers checks printed?.
PRINTERS
Are money orders, securities, or
travelers checks printed? No
Check the box (if applicable): Indicates a No response to the question, Are money
orders, securities, or travelers checks printed?.
PRINTERS
Does the applicant have a written
quality control program? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does the
applicant have a written quality control program?.
PRINTERS
Does the applicant have a written
quality control program? No
Check the box (if applicable): Indicates a No response to the question, Does the
applicant have a written quality control program?.
PRINTERS
Are customers required to proof-
read before printing takes place?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Are customers
required to proof-read before printing takes place?.
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Section Name
Field Name
Field and/or Section Description
PRINTERS
Are customers required to proof-
read before printing takes place?
No
Check the box (if applicable): Indicates a No response to the question, Are customers
required to proof-read before printing takes place?.
PRINTERS
Is the applicant a contract printer
for publishers? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is the applicant
a contract printer for publishers?.
PRINTERS
Is the applicant a contract printer
for publishers? No
Check the box (if applicable): Indicates a No response to the question, Is the applicant a
contract printer for publishers?.
PRINTERS
Does the applicant write
documents? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does the
applicant write documents?.
PRINTERS
Does the applicant write
documents? No
Check the box (if applicable): Indicates a No response to the question, Does the
applicant write documents?.
PRINTERS
How are solvents and/or other
pollutants disposed of?
Enter text: The description of how solvents and/or other pollutants are disposed.
VETERINARIANS
Are any services provided to
animals used or bred for
professional racing, show or
delivery services? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
services provided to animals used or bred for professional racing, show or delivery
services?.
VETERINARIANS
Are any services provided to
animals used or bred for
professional racing, show or
delivery services? No
Check the box (if applicable): Indicates a No response to the question, Are any services
provided to animals used or bred for professional racing, show or delivery services?.
VETERINARIANS
Are any services provided to
animals belonging to zoos,
circuses, carnivals, rodeos,
theatrical or other show
enterprises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or
other show enterprises?.
VETERINARIANS
Are any services provided to
animals belonging to zoos,
circuses, carnivals, rodeos,
theatrical or other show
enterprises? No
Check the box (if applicable): Indicates a No response to the question, Are any services
provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other
show enterprises?.
VETERINARIANS
# of Owners:
Enter number: The number of owners.
VETERINARIANS
# of Employed Vets:
Enter number: The number of employed veterinarians.
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Section Name
Field Name
Field and/or Section Description
REMARKS
Remarks
Enter text: The general remarks associated with professional liability. Use the remarks
area to document anything else that would help the underwriter evaluate your application.
Attach the ACORD 101, Additional Remarks Schedule, if more space is required.
EDITION
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
COVERAGE INFORMATION Hired Autos
Check the box (if applicable): Indicates the vehicle policy covers hired autos.
COVERAGE INFORMATION Other Covered Auto
Check the box (if applicable): Indicates the vehicle policy covers autos other than those
listed.
COVERAGE INFORMATION Other Covered Auto Description
Enter text: The description of the other covered autos.
COVERAGE INFORMATION Scheduled Autos
Check the box (if applicable): Indicates the vehicle policy covers scheduled autos.
COVERAGE INFORMATION Non- Owned Autos
Check the box (if applicable): Indicates the vehicle policy covers non-owned autos.
COVERAGE INFORMATION Other Covered Auto
Check the box (if applicable): Indicates the vehicle policy covers autos other than those
listed.
COVERAGE INFORMATION Other Covered Auto Description
Enter text: The description of the other covered autos.
COVERAGE INFORMATION Addl Insr
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured on the policy.
COVERAGE INFORMATION Subr Wvd
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the policy.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number. As used here, the
automobile liability policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY)
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the automobile policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY)
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the automobile policy expiration date.
COVERAGE INFORMATION Combined Single Limit $
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as
found on the policy declarations page.
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Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Bodily Injury (Per Person) $
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on
the policy declarations page.
COVERAGE INFORMATION Bodily Injury (Per Accident) $
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Property Damage
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as
found on the policy declarations page.
COVERAGE INFORMATION Other Description
Enter text: The description of the coverage.
COVERAGE INFORMATION Other Limit
Enter limit: The limit amount of the other coverage.
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the commercial excess umbrella liability policy.
COVERAGE INFORMATION Umbrella Liab
Check the box (if applicable): Indicates the type of policy is umbrella.
COVERAGE INFORMATION Excess Liab
Check the box (if applicable): Indicates the type of policy is excess.
COVERAGE INFORMATION Excess/Umbrella Liability - Occur
Type of Insurance -
Check the box (if applicable): Indicates coverage trigger is on an occurrence basis on an
excess or umbrella liability policy.
COVERAGE INFORMATION Claims-Made
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on an excess or umbrella liability policy.
COVERAGE INFORMATION Deductible
Check the box (if applicable): This indicates whether a deductible or retention amount
applies to the excess or umbrella liability policy.
COVERAGE INFORMATION Retention
Check the box (if applicable): Indicates the excess or umbrella liability policy has an
applicable deductible or retention amount.
COVERAGE INFORMATION $ Field Box
Enter deductible: The excess or umbrella liability deductible or retention amount.
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Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Addl Insr
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured on the policy. As used here, place a check mark
next to each coverage where an additional insured endorsement has been issued.
COVERAGE INFORMATION Subr Wvd
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the policy.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number. As used here, the
excess / umbrella policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY)
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the excess / umbrella policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY)
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the excess / umbrella policy expiration date.
COVERAGE INFORMATION Limits - Each Occurrence $
Enter limit: The excess umbrella liability limit each occurrence limit. As used here, the limit
should be listed as a whole dollar amount, as found on the policy declarations page. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
COVERAGE INFORMATION Aggregate $
Enter limit: The excess/umbrella liability aggregate limit should be listed as whole dollar
amount, as found on the policy declarations page. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s). As used
here, the limit should be listed as whole dollar amount, as found on the policy declarations
page. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Field Box
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s). As used here, the description of Other Excess /
Umbrella Liability Limit as found on the policy declarations page. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION $ Field Box
Enter limit: The excess umbrella liability limit other coverage limit. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the
policy declarations page. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
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Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the commercial workers compensation and
employers liability policy.
COVERAGE INFORMATION er/Member Excluded?
Type of Insurance - Workers
Compensation and Employers'
Liability - Any
Proprietor/Partner/Executive/Offic
Enter Y for a Yes response. Input N for No response. Indicates whether the workers
compensation and employers liability policy excludes any proprietor, partner, executive
officer, or member. As used here, this question is mandatory in New Hampshire.
COVERAGE INFORMATION Subr Wvd
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the policy.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number. As used here, the
workers compensation policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY)
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the workers compensation policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY)
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the workers compensation policy expiration date.
COVERAGE INFORMATION Limits - WC Statutory Limits
Check the box (if applicable): Indicates that workers compensation statutory limits apply.
COVERAGE INFORMATION Limits - Other
Check the box (if applicable): Indicates that additional coverage above the workers
compensation statutory limits applies (permitted in some states). Describe the additional
coverage in the Special Provisions section.
COVERAGE INFORMATION Field Box
Enter text: The description of other coverage (not the limit) on the workers compensation
and employers liability policy. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Each Accident $
Enter limit: The workers compensation and employers liability policy, employers liability
each accident limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Disease- EA Employee $
Enter limit: The workers compensation and employers liability policy, employers liability
disease each employee limit amount. Any questions about appropriate limits or applicable
policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit
should be listed as a whole dollar amount, as found on the policy declarations page.
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Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION E.L. Disease- Policy Limit $
Enter limit: The workers compensation and employers liability policy, employers liability
disease policy limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the other policy.
COVERAGE INFORMATION Type of Insurance - Other
Enter text: The description of the other policy not listed on the form.
COVERAGE INFORMATION Addl Insr
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured on the policy. As used here, place a check mark
next to each coverage where an additional insured endorsement has been issued or (for
umbrella/excess) there is an additional insured on the underlying primary policy and this
umbrella excess is follow form.
COVERAGE INFORMATION Subr Wvd
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the policy. As used here, this umbrella excess is follow form.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number. As used here, the
policy number of the other policy.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY)
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the effective date of the other policy,
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY)
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the expiration date of the other policy.
COVERAGE INFORMATION Limits
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s). As used
here, the limit should be listed as a whole dollar amount, as found on the policy
declarations page.
COVERAGE INFORMATION Locations / Vehicles
Description of Operations /
Enter text: The Certificate Of Liability Insurance general remarks. As used here, records
information necessary to identify the operations, locations and vehicles for which the
certificate was issued.
CERTIFICATE HOLDER
Certificate Holder Name & Address
Enter text: The certificate holder's full name.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address line one.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address line two.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address city name.
CERTIFICATE HOLDER
Enter code: The certificate holder's mailing address state or province code.
CERTIFICATE HOLDER
Enter code: The certificate holder's mailing address postal code.
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Section Name
Field Name
Field and/or Section Description
CANCELLATION
Authorized Representative
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
As used here, the authorized representative by all companies to issue Certificates.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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