W700000State and Casualty Insurance1234 Asgard RoadNewburgh, NY 12550

Banner, David 07 19 1952

201 Maple Circle 90 First Street

Catskill NY NY

21415 111 1111111

G7000000

Banner^^^David Y4 WC646-097

State and Casualty Insurance

Signature on File

01 05 2020 431 454 01 20 20200B 009200

DN Fury, Nicholas 4999888888

REFX5S983333-1^^^G2PSY^^^PWK06EAC00985621^^^NTEADD20200302

0F4312

OB 983333

01 20 20 01 20 20 11 90836 A 131 41 1 3999777777

981882222 90255920 131 41222 2222222

Natasha Romanoff, PhD Comprehensive NeuroPsych, Inc65 Marvel Boulevard 65 Marvel Boulevard

Natasha Romanoff, PhD Albany NY 12236 Albany NY 1223601/20/2020 3999777777 3777777777

987-65-4321

Green State Services

Claverack

12513 999 9999999

EXAMPLE - PSYCHOLOGIST

X