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~un ;17 03 30:33a <br />fIACF fAM1M <br />IHfVOANCI <br />LAtiEON.LTHOMAS E <br />AKELEY, <br />1255 19TH ST <br />HERM09A BEACH CA <br />STATUS:I'AID <br />AMT DUE: <br />,11 /1MM / <br />C5000 <br />D50 <br />G2 50 <br />H <br />STATE FRRM IMS <br />i <br />AU'1'0 POLICY <br />MUTL 0 <br />2000 E <br />90254-3309 vSN: <br />DUE DATE: <br />0.00 oXO:JUN-05-O1 <br />3~'1r.76 U1 100 <br />66.40 U1 <br />190.80 <br />2.40 <br />3103792436 <br />p.4 <br />JUNE 17, 2003 <br />US <br />H PHONE: 531.0) 372-1538 20 <br />6102-k'US-75A 1RG: <br />ZIP: 80254 <br />3231 CLASS: HF330A112 <br />WAG ACC FREE: JUN-OS-O1 <br />:R3346YJMO1.825 BIRTH: JUL-28-54 <br />4 DATE: TOT PREM: b39.50 <br />l DATE:DEC-OS-O1 PREV PREM: 610.07 <br />500 <br />300 <br />16.60 <br />42.22 <br />1,'16 <br />~~MT rAaD: 639.SO HATE PAID: JUN--06-03 <br />CDR 1 491.40, MCD 124.37, GGDD 159.88, <br />VSD 40$ 11.84, ODM 12000 0 601., MLD 68. 1. <br />NAME: LARSON,LINDA K 6 <br />REPLACED POLICY: 0376102-"15 <br />EXCEe. ~ END: ADD'I• I13SURED - THE CITY <br />DRVRNTS, DT OF LICTERLSNXT RLVDT CEN7.'E~ <br />LINDA 07/2B/1970 1 SR-06/05/2004 <br />REC CHG: <br />COV. S & Z NAMES 5 AMT Z <br />At'i'i()w'I:l:~ ~\S 6't) F'ORNa' <br />~` r <br />r I~ +~ _...._._._~~~~, <br />.its <~il~ ~l [urarY <br />H PHONE: 1310) :372-1538 <br />FOI.ICY FORM: 9805A <br />IL'I.A7,ATSANTA ANA OFAFIGe`~RSO~ EMPLOXL'ES, <br />^.~/CONV DATE INFORMATION <br />