%PDF-1.1
%âãÏÓ
1 0 obj
<<
/CreationDate (D:19971217145746)
/ModDate (D:20190312112423-05'00')
/Producer (Acrobat Distiller 2.0 for Windows)
>>
endobj
2 0 obj
<<
/AcroForm 3 0 R
/Metadata 4 0 R
/Pages 5 0 R
/Type /Catalog
>>
endobj
3 0 obj
<<
/DR <<
/Font <<
/F0 6 0 R
/F1 7 0 R
>>
>>
/Fields []
>>
endobj
4 0 obj
<<
/Length 2913
/Subtype /XML
/Type /Metadata
>>
stream
1997-12-17T09:57:46-05:00
2019-03-12T11:24:23-05:00
application/pdf
uuid:a8cf1801-bb00-47b6-976e-64791079e9c0
uuid:a1f282e0-94f3-440f-8ed3-5c12c7c10e2b
Acrobat Distiller 2.0 for Windows
endstream
endobj
5 0 obj
<<
/Count 1
/Kids [8 0 R]
/MediaBox [0 0 612 792]
/Type /Pages
>>
endobj
6 0 obj
<<
/BaseFont /Helvetica
/Subtype /Type1
/Type /Font
>>
endobj
7 0 obj
<<
/BaseFont /CourierNewPSMT
/Encoding /WinAnsiEncoding
/FirstChar 32
/FontDescriptor 9 0 R
/LastChar 255
/Subtype /TrueType
/Type /Font
/Widths [600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 0 600 600 600 600 600 600 600 600 600 600 600 0 600 0
0 600 600 600 600 0 600 600 600 600 600 600 600 0 600 600
0 600 600 600 600 600 600 600 600 600 600 600 600 0 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600
600 600 600 600 600 600 600 600 600 600 600 600 600 600 600 600]
>>
endobj
8 0 obj
<<
/Annots [10 0 R]
/Contents 11 0 R
/Parent 5 0 R
/Resources 12 0 R
/Thumb 13 0 R
/Type /Page
>>
endobj
9 0 obj
<<
/Ascent 833
/CapHeight 571
/Descent -300
/Flags 32
/FontBBox [-122 -680 623 1021]
/FontName /CourierNewPSMT
/ItalicAngle 0
/StemV 0
/Type /FontDescriptor
>>
endobj
10 0 obj
<<
/AP <<
/N 14 0 R
>>
/BS <<
/W 0
>>
/CreationDate (D:20181219162418-06'00')
/DA (0 0 0 rg /F1 12 Tf)
/DS (font-family:Courier New;font-size:12pt;font-style:normal;text-decoration:none;color:#000000;)
/F 4
/IT /FreeTextTypewriter
/M (D:20181219162418-06'00')
/NM (ce64cd2a-58a6-4740-bba021826d164564)
/P 8 0 R
/Rect [300 581.903992 305 595.5]
/Subj (Typewriter)
/Subtype /FreeText
/T (award)
/Type /Annot
>>
endobj
11 0 obj
<<
/Length 2781
>>
stream
0 G
1 i 0 J 0 j 0.2 w 10 M []0 d
17.75 670 m
244.75 670 l
S
17.75 682 m
244.75 682 l
S
60.75 466 m
550.75 466 l
S
60.75 490 m
550.75 490 l
S
60.75 514 m
550.75 514 l
S
60.75 538 m
550.75 538 l
S
60.75 562 m
550.75 562 l
S
60.75 586 m
550.75 586 l
S
60.75 610 m
550.75 610 l
S
60.75 634 m
550.75 634 l
550.75 442 l
60.75 442 l
60.75 634 l
S
129.25 682 m
129.25 670 l
S
219.25 634 m
219.25 442 l
S
305.75 634 m
305.75 442 l
S
392.25 634 m
392.25 442 l
S
0.4 w
60.75 214 m
75.25 214 l
75.25 202 l
60.75 202 l
60.75 214 l
S
60.75 238 m
75.25 238 l
75.25 226 l
60.75 226 l
60.75 238 l
S
60.75 383 m
147.25 383 l
S
111.25 71 m
500.25 71 l
S
111.25 107 m
500.25 107 l
S
111.25 143 m
399.25 143 l
S
204.75 226 m
248.25 226 l
S
334.75 407 m
550.75 407 l
S
413.75 143 m
500.25 143 l
S
449.75 383 m
550.75 383 l
S
0.75 w
17.75 658 m
593.75 658 l
S
17.75 742 m
593.75 742 l
S
244.75 742 m
244.75 658 l
S
507.25 766 m
507.25 742 l
S
1 w
17.75 766 m
593.75 766 l
593.75 34 l
17.75 34 l
17.75 766 l
S
BT
/F1 1 Tf
16.8 0 0 16.8 104.25 747 Tm
0 Tr
0 g
0 Tc
0 Tw
(AGENT/BROKER OF RECORD CHANGE)Tj
13.8 0 0 13.8 60.75 406 Tm
0.05 Tw
(Please be advised that we wish to name)Tj
6.812 -1.739 TD
0.41 Tw
(as our exclusive representative effective)Tj
-6.812 -1.739 TD
0.209 Tw
(for the lines of business shown above, currently in force or submitted)Tj
0 -1.304 TD
0 Tw
(by application.)Tj
0 -2.899 TD
0.182 Tw
(This authorization replaces any other authorization that may have been)Tj
0 -1.304 TD
0.413 Tw
(previously completed for any other insurance representative for the)Tj
T*
0 Tw
(stated lines of business.)Tj
1.594 -2.609 TD
[(Please rescind the)-3718(day waiting period)]TJ
0 -1.739 TD
(There will be no rescission letter)Tj
8.4 0 0 8.4 21.25 25.5 Tm
(ACORD 36 \(1/98\))Tj
4.5 0 0 4.5 466.75 26.5 Tm
(c)Tj
/F2 1 Tf
7.2 0 0 7.2 464.75 25.5 Tm
(O)Tj
/F1 1 Tf
8.4 0 0 8.4 472.152 25.5 Tm
(ACORD CORPORATION 1996)Tj
5.9 0 0 5.9 542.72 755.5 Tm
(DATE)Tj
-88.385 -3.559 TD
(PRODUCER)Tj
38.475 0 TD
(INSURANCE COMPANY NAME)Tj
-38.475 -10.593 TD
[(CODE:)-15676(SUBCODE:)]TJ
0 -1.356 TD
(AGENCY)Tj
0 -0.932 TD
(CUSTOMER ID:)Tj
15.308 -6.864 TD
[(POLICY NUMBER\(S\))-11651(EFFECTIVE DATE)-5770(EXPIRATION DATE)-11539(LINE OF BUSINESS)]TJ
/F2 1 Tf
7.2 0 0 7.2 422.151 398.5 Tm
(PRODUCER)Tj
-46.014 -3.333 TD
(CODE #)Tj
55.528 0 TD
(DATE)Tj
-38.445 -33.681 TD
[(INSURED'S SIGNATURE)-20902(DATE)]TJ
7.29 -5 TD
(TITLE \(IF APPLICABLE\))Tj
-2.75 -5 TD
(COMPANY NAME \(IF APPLICABLE\))Tj
/F1 1 Tf
15.7 0 3.337 15.7 29.75 749 Tm
(ACORD)Tj
ET
0.4 w
29.75 748 m
84.75 748 l
S
BT
/F1 1 Tf
3.8 0 0 3.8 86.25 746.5 Tm
(TM)Tj
ET
endstream
endobj
12 0 obj
<<
/ColorSpace <<
/DefaultRGB 15 0 R
>>
/Font <<
/F1 16 0 R
/F2 17 0 R
>>
/ProcSet [/PDF /Text]
>>
endobj
13 0 obj
<<
/BitsPerComponent 8
/ColorSpace [/Indexed /DeviceRGB 255 18 0 R]
/Filter [/ASCII85Decode /LZWDecode]
/Height 99
/Length 910
/Width 77
>>
stream
J2Q7]3$]7K#D>EP:q0C-)%VNk@Sg`[:+[9@2<(XWjE<[.O@Wn[3@'.X-&k0TNH2Cs
""u/iV=P"`[V%Hu9BR]@[,-!cRDPe>391]R)i[?5oN9WFPtROcAF4ZuWB-
3+tbko8CUSYI)AFZQ#$]?0X@2L16!PYhh$,W0Zn2VN0\eY(5k+ZFi2\;ISuBU7Ece6./AmRVX6XL^)+J?SFUkpD'/L3.
aDuI(7*5k:YpJrBSGpFL>:?r%M_o,(/I\qA-,VF,FS3Mq]N$/pM?96>bL&AjLIGsp
DP"T1\qZs!&rUlk`X=P'2U0[5h%EIt<:o._Xcd_+cgmkCl:UWKP=!XDbn/mGmDS`h
c;S4DdAX$dU9%-GUM?VSZdQjm:[ReL+&[1ho28PF\uR[7l_C@b"ZtgZEU6i
13f;0$!M1!eHqtJ>URqs>6i_9>d33&M6_H!=fT_qpe[8Umo`doXg7oTe>![Te?n8Z
=K1s#TfYp=gf8>In`@4Q:%^(');Pau\PU]]Q-W6%QQ>rk>?"o2J6geC$\D"'7BqJR
0a$k2`u"\e2;YF[,e7?h^'@!bGh*B'@^+CHCKgNSXcCG)6q*AMe'+(C4ughdO5n=9
9q1;`]$@+ib.XdGb]gp8Os0%lLkb-W=KI%'~>
endstream
endobj
14 0 obj
<<
/BBox [300 581.903992 305 595.5]
/Filter [/FlateDecode]
/Length 34
/Matrix [1 0 0 1 -300 -581.903992]
/Resources <<
>>
/Subtype /Form
/Type /XObject
>>
stream
xÚ360P0µ0Ô³40Q0U04Ö3µ4S(JåÊã CŽA
endstream
endobj
15 0 obj
[/CalRGB <<
/Gamma [1.8 1.8 1.8]
/Matrix [0.4497 0.2446 0.02518 0.3163 0.672 0.1412 0.1845 0.08334 0.9227]
/WhitePoint [0.9505 1 1.089]
>>]
endobj
16 0 obj
<<
/BaseFont /Helvetica-Bold
/Name /F1
/Subtype /Type1
/Type /Font
>>
endobj
17 0 obj
<<
/BaseFont /Helvetica
/Name /F2
/Subtype /Type1
/Type /Font
>>
endobj
18 0 obj
<<
/Filter [/ASCII85Decode /LZWDecode]
/Length 459
>>
stream
J,g]g+e/h_!_gCtO=0f)$P%cIi8Zdfc5&3j_8$7g.@L`YKUJNGBP\poR=_;Dl'P(T
(7Boo^^S:71(MN]ZQX/+Cbu.lK"p74pe1T%s.DY%&\1TdJhr54.M9au6>79n6`Q:4
PbLSZTLEE(8E@'*1mg_*eTnN*;*'V3+gm-EEetX%;Bo$ur2ss*N`.-!.kG_q6GDD'
dKoL!8Ka#EV,@V!\j8ZFbp6EE<9cn=N6j0nf;(&;QU6bUD')c@\
9-d\DA=cZ0Q>gIM$$;cd2O@&a;X,Nn_aP(]I1aRc(K1^ue>
gF/(+GaKo$qneLWDrQ#;5\S(\$q'LM9bYJX9N;hHO_e;>`Y"/'J:I~>
endstream
endobj
xref
0 19
0000000000 65535 f
0000000015 00000 n
0000000150 00000 n
0000000231 00000 n
0000000305 00000 n
0000003300 00000 n
0000003381 00000 n
0000003451 00000 n
0000004496 00000 n
0000004609 00000 n
0000004784 00000 n
0000005209 00000 n
0000008043 00000 n
0000008158 00000 n
0000009242 00000 n
0000009465 00000 n
0000009621 00000 n
0000009707 00000 n
0000009788 00000 n
trailer
<<
/ID [<88FB42F9BBBB4EC61C3E84F3F89D8E72> <88FB42F9BBBB4EC61C3E84F3F89D8E72>]
/Info 1 0 R
/Root 2 0 R
/Size 19
>>
startxref
10335
%%EOF