Fillable Application - Educators Professional Select PIIC - MA36-11164

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Application - Educators Professional Select PIIC - MA36-11164

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THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE CONSULT WITH YOUR AGENT FOR ANY QUESTIONS.
SUBMISSION REQUIREMENTS
•
Currently valued insurance company loss runs for the current policy period plus four prior years
•
Latest annual audited financial statement
This application must be signed and dated by the executive officer of the Educational Institution or by a member of its governing board.
SECTION I – GENERAL INFORMATION
Educational Institution:
Mailing Address:
City: State: Zip Code:
Website Address: www.
Effective Date:
1. Risk Management Contact: Risk Management Phone:
Risk Management’s Email:
2. Date Educational Institution was founded:
3. Are all entities requesting coverage recognized as 501(c)(3), tax exempt organizations by the
Internal Revenue Service?
Yes
No
4. Please describe the Educational Institution:
Public Private Not For-Profit
Charter 2 or 4 year College or University Professional / Graduate
(e.g. Law, Dental, Medical)
Other:
5. Student Enrollment Profile
Prior Year
Full Time / Part Time
Current Enrollment
Full Time / Part Time
Expected Next
Full Time / Part Time
K - 8 / / /
9 - 12 / / /
2 or 4 year undergraduate / / /
Graduate / / /
Other: / / /
Total / / /
6.
Financials
Year
Revenues
Surplus (+) Deficit (-)
Current Year
$
Prior Year
$
Previous Year
$
7.
If a deficit, provide details about the reason(s) for the deficit and the Educational Institution’s plans
to fund the deficit:
8.
Was this deficit projected in the Educational Institution’s plan last year?
Yes
No
9.
Is the Educational Institution projecting a budget deficit for the coming fiscal year?
Yes
No
For-Profit
Special Needs /
Behavioral
EDUCATORS PROFESSIONAL SELECT APPLICATION
PI-EPS-APP NB MA (01/16)
PI-EPS-APP NB MA (01/16)
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10.
Coverage desired: Combined limits
Separate limits
Type of Insurance
Requested Limit
Requested
Retention
Proposed
Effective Date
Requested
Retroactive Date
Optional
Educators Legal Liability
$
$
Employment Practices Liability
$
$
Wage and Hour
$100,000
$250,000
Nonmonetary Defense Expense
Limit
$ 10,000 / $ 30,000
$ 1,000
$ 25,000 / $ 75,000
$ 2,500
$ 50,000 / $150,000
$ 5,000
$100,000 / $300,000
$10,000
$25,000
Fiduciary Duty Defense Sublimit
$ 50,000
$
$ 75,000
$100,000
$250,000
11.
Describe below the Educational Institution’s current insurance, or “none” as applicable.
Are limits: combined or separate
Type of
Insurance
Insurer
Limit
Policy Term
Retroactive /
Prior Acts
Date
Deductible /
Retention
Expiring
Premium
Directors &
Officers Liability
$
$
$
Educators Errors
& Omissions
Liability
$
$
$
Employment
Practices
Liability
$
$
$
Cyber Liability
$
$
$
12.
Has any of the above lines of coverage been declined, refused, canceled or non-renewed within
the past five (5) years? (Missouri applicants need not respond to this question.)
Yes
No
If yes, please provide details:
13.
Has each coverage listed above been continuously in place since its retroactive date?
Yes
No
If no, please explain gaps or lapses:
SECTION II – EDUCATORS LEGAL LIABILITY
For all Yes answers provide explanation on page 7 of this application.
14.
Number of members comprising the governing board of the institution:
15.
Does the Educational Institution publish any magazines, periodicals or newsletters?
Yes
No
16.
Have there been any acquisitions, mergers, or new entities created in the past year?
Yes
No
17.
Are any planned within the next 12 months?
Yes
No
18.
Provide a list of all direct &indirect subsidiaries or any other entity or organization the Educational Institution
controls.
Name / Type of Business
Percent the
Educational Institution
Owns / Controls
Date Created /
Acquired
For Profit /
Non-Profit
For example: ABC Foundation / Charitable Foundation
100% 01/01/2000 Non-Profit
Additional entities listed by attachment
%
%
%
PI-EPS-APP NB MA (01/16)
PI-EPS-APP NB MA (01/16)
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19.
Does the Board have "conflict of interest" guidelines for business dealings between the Educational
Institution and board members or firms in which the board members have a significant financial
interest?
Yes
No
20.
Does the Educational Institution direct or request any individual to serve as Director, Officer, or
Governor or trustee of any other entity?
Yes
No
If yes, please provide details on page 7.
21.
In the past 24 months, has any officer or director or member of the governing board resigned, for
reasons other than health, promotion, retirement or expiration of term of office?
Yes
No
If yes, please provide details on page 7.
22.
Does the Educational Institution’s board have written bylaws or an operating agreement?
Yes
No
If yes, please provide a copy.
23.
Is the Educational Institution accredited?
Yes
No
If yes, list accrediting organization(s):
Middle States Commission on Higher Education
New England Association of Schools and Colleges Commission on Institutions of Higher Education
North Central Association of Colleges and Schools The Higher Learning Commission
Northwest Commission on Colleges and Universities
Southern Association of Colleges and Schools Commission on Colleges
Western Association of Schools and Colleges Accrediting Commission for Community and Junior Colleges
WASC Senior College and University Commission
New York State Board of Regents
Accrediting Council for Independent Colleges and Schools
Distance Education and Training Council Accrediting Commission
Association for Biblical Higher Education Commission on Accreditation
Association of Advanced Rabbinical and Talmudic Schools Accreditation Commission
The Association of Theological Schools in the United States and Canada Commission on Accrediting
Transnational Association of Christian Colleges and Schools Accreditation Commission
Other:
Date of most recent review:
24.
Have any programs or degrees been accredited by additional specialist agencies?
Yes
No
If yes, please attach a listing of the program or degrees and the specialist agency.
25.
Has the Educational Institution or any of the Educational Institution’s academic programs ever lost
accreditation, been placed on probation or become unable to gain accreditation?
Yes
No
26.
In the last 12 months, has the Educational Institution eliminated or closed any academic programs,
including music, arts or athletic programs?
Yes
No
27.
In the next 12 months, does the Educational Institution anticipate eliminating or closing any academic
programs?
Yes
No
28.
Other than educational services for students, does the Educational Institution provide any additional
services to the public (e.g., legal or other clinics, student teaching programs, community outreach
services)?
Yes
No
29.
Does the Educational Institution have a written anti-discrimination policy regarding admissions and
access to academic and extracurricular programs with regard to students of all backgrounds?
Yes
No
If no, please explain:
30.
Has the Educational Institution designated a Title IX compliance officer?
Yes
No
31.
Is there an intern Program?
Yes
No
32.
Indicate which of the following internship programs are offered by the Educational Institution:
NA
Architectural
Athletic training
Audiology
Dental hygienists/assistants (dentists ineligible)
Paramedics, EMTs (emergency medical services)
Engineering (aerospace, nuclear, petroleum, and mining ineligible)
Law
Nurse practitioners (midwives and anesthetists ineligible)
Nursing (other than nurse practitioners; midwives and anesthetists ineligible)
Optometry
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Pharmacy
Physical therapy
Physicians' assistants (midwives and anesthetists ineligible) work and sociology)
Psychology (not including social work and sociology)
Social work (including but not limited to child therapy, marriage therapy, counseling)
Speech/language therapy
Veterinarian
None of the above
33.
Do interns receive monetary compensation?
Yes
No
34.
Who is legally liable for the actions of the interns:
35.
Has entity / board established policies/procedures governing all students in the area of:
Yes
No
In Writing
Acceptance/Admittance
Corporal Punishment
Disciplinary actions, including suspension, expulsion/dismissal and
appeals of any disciplinary action
Harassment / Bullying (social media)
Harassment / Bullying (In person)
Use of Alcohol
Academic Achievement and Grade Promotion
Transfer (to or from the school)
Threats of Violence
36.
Have the Educational Institution’s policies and procedures been reviewed by counsel?
Yes
No
37.
Is the Educational Institution’s attorney:
an employee of the entity or on retainer
38.
Does the Educational Institution’s attorney regularly participate in all grievances or administrative
hearings?
Yes
No
CHARTER SCHOOLS COMPLETE QUESTIONS 39 – 42 N/A
39.
Does the Educational Institution have direct control over its own finances?
Yes
No
If no, please explain:
40.
What is the percentage of students in the
Educational Institution
that have IEP’s (Individualized
Education Plans): %
41.
How many IEP due process hearings has the
Educational Institution
had in the past two years:
42.
Is the Educational Institution responsible for evaluations, adjustments to IEPs and mainstreaming?
Yes
No
If no, please explain who is responsible:
SECTION III – EMPLOYMENT PRACTICES LIABILITY
For all Yes answers provide explanation on page 7 of this application.
43.
Please indicate the number of employees in the following categories:
a.
Certified Teaching Faculty
b.
Non-certified Teaching Faculty
c.
Administration
d.
Counselors / Psychologists
e.
Volunteers
f.
Security / Law Enforcement
g.
Other:
h.
Total Number of Employees
44.
Does the Educational Institution have a Personnel or Human Resources department?
Yes
No
If no, how does the Educational Institution handle this function?
45.
Are federal and state criminal background checks conducted on all employees?
Yes
No
a.
If yes, is an offer of employment contingent upon such checks, and is the Educational
Institution
aware of this requirement?
Yes
No
b.
If no, what employees are not subject to criminal background checks:
46.
Are exit interviews mandatory for professional positions? (e.g. faculty and administration)
Yes
No
PI-EPS-APP NB MA (01/16)
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47.
Has the Educational Institution had any school closings, layoffs or restructuring resulting in workforce
reduction in the past 24 months?
Yes
No
If yes, please provide details on Page 7
48.
Does the Educational Institution
anticipate any school closings, layoffs or restructuring resulting in
workforce reduction in the next 24 months?
Yes
No
49.
Does the Educational Institution offer tenure?
Yes
No
a.
If yes, what percentage of employees are tenured or on a "tenure track”? %
b.
If the Educational Institution offers tenure, are there clear written guidelines regarding awarding of
tenure?
Yes
No
c.
Is policy training conducted annually for all individuals involved in tenure decisions?
Yes
No
50.
Does the Educational Institution require that all cancellations of contracts or employment terminations
of professional, teaching or management positions be reviewed prior to discharge by a qualified
employment lawyer?
Yes
No
a.
For those not employed under a contract, is a written employment application used for all of the
applicants?
Yes
No
b.
Does each employee not employed under a contract sign an "at will" statement?
Yes
No
51.
Over the last 2 years, how many teaching, professional and senior administration individuals have left
the Educational Institution’s employ due to the following:
Current Year
Prior Year
Involuntary terminations
Resignations (other than retirement)
Layoffs / downsizing
52.
Does the Educational Institution have an employee handbook with written policies and procedures
regarding the following?
a.
Americans with Disabilities Act
Yes
No
b.
Employee Discipline
Yes
No
c.
Employment Related complaints or disputes
Yes
No
d.
Sexual Harassment
Yes
No
e.
Terminations
Yes
No
f.
Performance Evaluations
Yes
No
g.
Equal Employment Opportunity
Yes
No
h.
Family Medical Leave Act (FMLA)
Yes
No
i.
Third Party (e.g. vendors or customers) harassment and discrimination
Yes
No
53.
If coverage is desired for Wage and Hour Defense Costs Sublimit, please complete questions 54-61:
NA
54.
Does the Educational Institution consult with an attorney regarding how overtime is calculated and how
they define “Exempt” employees for each location?
Yes
No
55.
Does the Educational Institution
have established procedures for maintaining job descriptions for each
employee at each location?
Yes
No
56.
Does the Educational Institution
periodically have job description reviewed and / or updated?
Yes
No
If yes, are they performed with assistance of an attorney?
Yes
No
57.
Does the Educational Institution periodically have each job description reviewed and compared to the
employee’s actual job duties?
Yes
No
58.
Does the Educational Institution
keep records of employee’s hours?
Yes
No
59.
Does the Educational Institution restrict employees to non-overtime hours where possible?
Yes
No
60.
Does the Educational Institution use an overtime authority form?
Yes
No
61.
What percentage of the Educational Institution’s employees are exempt: %
SECTION IV – PRIOR KNOWLEDGE AND LOSS INFORMATION
For all Yes answers provide explanation on page 7 of this application.
62.
Have any of the following situations occurred during the past 5 years:
a.
Allegations of unfair or improper treatment regarding employee hiring, tenure decisions,
remuneration, advancement or termination of employment?
Yes
No
b.
Disputes involving integration, segregation, discrimination or violation of civil rights?
Yes
No
c.
Allegations of sexual molestation, abuse or harassment against any:
i.
Students?
Yes
No
ii.
Current or Former Employee?
Yes
No
iii.
Other?
Yes
No
PI-EPS-APP NB MA (01/16)
PI-EPS-APP NB MA (01/16)
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d.
Complaints filed with the EEOC, Office of Civil Rights, Human Rights Commission, United
States Department of Education, State or Federal Court, or any similar State or Federal
agency by any person, current or former employee or job applicant?
Yes
No
e.
Layoff of employees or reduction in services?
Yes
No
f.
Strike, slowdown or other disruption by employees?
Yes
No
63.
Does the Educational Institution, its board and/or trustees, “Reporting Manager” or its employees
have any knowledge of any pending claims, suits, incidents, settlements, demands, complaints,
charges, or proceedings related to actual or alleged acts, errors or omissions, which might
reasonably be expected to give rise to a claim against the Educational Institution, the board and/or
its trustees, or any of its employees? “Reporting Manager” means any natural person serving as
President/CEO, Chancellor, Provost, Chief Financial Officer, Head of School, Principal,
Superintendent, General Counsel, Chief Risk Officer, Director of Human Resources or any
position equivalent to the foregoing, of the educational entity(ies) requesting insurance?
Yes
No
a.
If yes, has the current E&O carrier been placed on notice of such pending injury, claim, suit,
error or omission?
Yes
No
b.
If yes, please provide claimant name(s), claim details, claim number and date of notice:
The Educational Institution
acknowledges that the insurance policy for which it is applying does
not afford coverage with respect to any claim which could reasonably have been expected to arise
from facts, circumstances, situations or wrongful acts known to the Educational Institution
prior to
the inception date of a policy issued as a result of this application process.
SECTION V – NOTICES
The information requested in this application is for underwriting purposes only and does not constitute notice to the Company
under any policy of a claim or potential claim. All such notices must be submitted to the Company pursuant to the
terms of the policy.
Material Change
This application does not create a binding contract as to the Educational Institution or the Company. If there is any
material change in the answers to the questions in this application prior to the policy inception date, the Educational
Institution
shall notify the Company in writing. The undersigned acknowledges and agrees that the Company’s receipt of
such written report, prior to inception date of the proposed coverage, is a condition precedent to any offer of coverage.
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ADDITIONAL INFORMATION
This pag
e may be used to provide additional information to any question on the application. Please identify the
question number to which you are referring. Please refer to the question number in your response.
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company.
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_______________________
______________________________________
SIGNATURE DATE
SECTION TO BE COM
PLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
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