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<br />In <br />.. <br />'" <br />.... <br />... <br /> <br />.... <br />::: <br />.:> <br />"" <br />Cl'\ <br />... <br />~ <br />... <br />... <br />"" <br />.:> <br />... <br />:!I <br /><< <br /> <br />!!!!! <br />- <br />... <br />II <br />~ <br />~ <br />- <br />- <br /> <br />- <br />- <br />iiii <br />- <br />== <br />- <br />-= <br />- <br />- <br />- <br />..... <br />..... <br />IIiiIiio <br />"""" <br />- <br />- <br />- <br />- <br />iI <br />lIB <br />- <br />~ <br />== <br />!!!II <br />..... <br />- <br />- <br />- <br />iii <br />-- <br />- <br /> <br />02128/2005 12:30 <br /> <br />5192397105 <br /> <br />NEW CITY AMERICA <br /> <br />PAGE 03 <br /> <br />ThIS SPECIAL MULTI-FLEX POUCV is puvIdecl by the InslllllnCll compuy(s) ofTh. Hllrtrord lnsuranoe Group .. <br />shoWII below. . <br /> <br />COMMON POLICY OeCLARA TIONS <br /> <br />POLICY NIJ..-8E'R: '72 UlIC! :IL99!1J m <br />RBIIilKl\L 01'. '72 tJBC nlDD3 <br />NiImed lnsuNd and Mailing Adclnlsr. - CZft -..,.:tQI ZE <br />(No.. .....It, Town. Stale. ZIp Cade) <br /> <br />THB. <br /> <br />HARTFORD <br /> <br />.:11>>0 =....11. ,j- --.: <br />... ~ . 1:& Inll <br />(... DmIIO ~wn;..) <br /> <br />Policy Period: Jrrom O:il/2J/06 To 02/23/07 <br />12.01 A..., SIllnclanl tllllll81 yourmallinQ addl'll$5shoMl abO\I8. <br />In return for the p.ymerrt afllt", premium. and lIlIbjed to d of the terms of this poiii:)', we ag.... with you to provide <br />iI1sl1l1lnoe lIS stated in thia polIc:lJ. TIuI Cmml'llll'" PllltS tna! are II JI8If lIt'thls policy are fislell beloW. Tbe AdvIlnC8 <br />""'mum ahuwn may be subject to Id,\usIJlllInL <br /> <br />Total AdIIance PnImi.....: <br /> <br />~Pllrt amIlll1Ul1I... company summarv <br /> <br />C'.........CIAL AtI'l'O <br />!IAR'.W'QN) ~ mSllIWlCB CCIIG'Ml!" <br />IWCl'I'ORD PLAZA. <br />~. ~l:CU'l' 061.15 <br /> <br />$1,866.00 <br /> <br />AdvanCe Premiwn <br /> <br />$1,866.00 <br /> <br />Form NUmbel1l t:tI COWlI\I!Pl Pa... Fonna lIIId Endor....- ttm_ a part C)f tIIII polil:y..... tIlllt an! not <br />IiSt8d in the CoVll!Pl98 PlIras. <br /> <br />BMOOOl IL001711!18 IH09850106 lL002~0702 !t02701104 ~Q250302 <br /> <br />AgIntI8rvlcer WarM: ~... ~-liJ -~ aD ~ AIWII/- <br /> <br />11Iill poIk:y is nllllllindinll unIMs c:ountersirlWd by CIIll' AutfIorized Rep.. 1.....11.... <br /> <br />OounllllSigntId by <br /> <br />lV\.o.(~ ~. .~ <br />AlllI10rtzBd ReprMentsliw <br /> <br />tlKIQ:.amL <br />fonn HM 00 10 112 M <br /><:9 39t'd <br /> <br />l.ZO I hl\lll :nun <br /> <br />9ge~EEC:G~9 <br /> <br />19;0~ 9AA7./RZ/~~ <br /> <br />42/05/05 <br />Date <br />