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01/01/2005 00:20 12094737016 JACKINTHEBOX486 PAGE 03 <br /> SAF T A <br /> 486 Ph�ZZANl'r <br /> f4 dZESAN.4GrR <br /> M0NTI1 lyVI , I'OIa1C;ti/l <br /> SST!E�S 1)XSf.'C'SS1:11 <br /> 111.�t Y 7 1?1 <br /> 1),/J NI,7 UN,UE RS 7;9 ND TYL MQNTHL Y TOP,le— <br /> �tAME SIGNATURE <br /> 17 <br /> K <br /> 1 <br /> FARMERS INSURANCE <br />