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The document appears to be a form or table related to insurance premiums, specifically for workers' compensation and general liability. Here is the transcription of the visible text:

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**Table I**

Premium Subject to Part II, Insurance Law, Coverage Form, State Tax Multiples

| Description of Liability | Amount |
|--------------------------|--------|
| Bodily Injury | $100,000 |
| Property Damage | $100,000 |
| Bodily Injury + Property Damage | $100,000 |
| Bodily Injury + Property Damage (including medical costs) | $100,000 |
| Bodily Injury + Property Damage (including medical costs) | $1,000,000 |
| General Liability - Property Damage | $100,000 |
| General Liability - Property Damage (including medical costs) | $100,000 |
| General Liability - Property Damage (including medical costs) | $1,000,000 |
| General Liability - Property Damage (including medical costs) | $1,000,000 |

* Included with Bodily Injury

**State Tax Multiples**

| Name of State | A/G | 1st | 2nd | 3rd | 4th | 5th | 6th | 7th | 8th | 9th | 10th | 11th | 12th | 13th | 14th | 15th | 16th | 17th | 18th | 19th | 20th | 21st | 22nd | 23rd | 24th | 25th | 26th | 27th | 28th | 29th | 30th | 31st | 32nd | 33rd | 34th | 35th | 36th | 37th | 38th | 39th | 40th | 41st | 42nd | 43rd | 44th | 45th | 46th | 47th | 48th | 49th | 50th | 51st | 52nd | 53rd | 54th | 55th | 56th | 57th | 58th | 59th | 60th | 61st | 62nd | 63rd | 64th | 65th | 66th | 67th | 68th | 69th | 70th | 71st | 72nd | 73rd | 74th | 75th | 76th | 77th | 78th | 79th | 80th | 81st | 82nd | 83rd | 84th | 85th | 86th | 87th | 88th | 89th | 90th | 91st | 92nd | 93rd | 94th | 95th | 96th | 97th | 98th | 99th | 100th | 101st | 102nd | 103rd | 104th | 105th | 106th | 107th | 108th | 109th | 110th | 111th | 112th | 113th | 114th | 115th | 116th | 117th | 118th | 119th | 120th | 121st | 122nd | 123rd | 124th | 125th | 126th | 127th | 128th | 129th | 130th | 131st | 132nd | 133rd | 134th | 135th | 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