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CG D4 58 0713 0 2013 The Travelem Indemnity Company, All dghts reserved, Page 3 of 7 <br />Includes copyrighted material of insurance Services Office, Inc. with its permission <br />FR E V"11 E V,V-E"D- B Y EUNRCE HERELAA (FIG 110F <br />-- ----------- <br />