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965 <br />POBOX981030 ~~` ~~~~tv~}~~;~,,~ <br />ti <br />WEST SACRAMENTO CA 95798 <br />916 635-1173 <br />ZURICH-AMERICAN INSURANCE GROUP <br />Please Note: <br />We have a new mailing address for <br />our claim office. Please use the above <br />address for any future correspondence. <br />MARION COUNTY OREGON/ATTN: RISK SERVICES <br />3150 LANCASTER DR. N.E. <br />SALEM OR 97305 <br />03481 <br /> THE FACE OF THIS DOCUMENT HAS A BLUE BACKGROUND - NOT A WFqTE Bqq(GRpUND. i}IE BACK OF THIS DOCUMBVT HAS A SIMULATED WATERMARK HOLp AT <br />- <br /> ~ ~~ ~ ~ ~ ~~ ~~ ~ : AN MIGl E TO VIEW. <br />~ <br />- ~~;ZURICH A1VI~?31CAM1RISUR~ <br />I~~E°.~~~liFiR~t~ <br />~~~ _ ~~ <br />. ~~ <br /> , <br />, <br />~ .. <br />,, ~o=2s2anis <br /> <br />~ ~~ <br />~ , <br />~ <br /> - _ <br />= - <br />- ~ , ~ ~,r ` ~~ <br />~~ '~sox~~apsQ = _ _ = _ ~~, , ~~ ;i <br />~ ~ ~, <br />~ <br />Z~~~ <br />~ <br />I~VEST SACF3AM <br />EN3'O CA 9579~ <br />` <br />~ „ <br /> , <br />~ <br /> ,~;' <br /> , <br />,, , <br />~ <br />. <br />~ <br />` - <br /> ~ti <br />; <br />_ <br />° ~ ~ <br />~ `, <br />;~ , <br /> Amount y""Vyp ~/~`j~/~A~yp~ ~yp H{~~yDAED EIGHTY FiV,~,i~ND Od'lik~l _ ~----------DOLiARS - ~~ ~ ~ ~ ~ <br /> ~ <br /> ~' <br />Pay4+~~ pence kelly~cor~str~ac#ion ~ ~~ ~ <br /> ~~ <br />~ ` <br />PAY THIS SUM ~ ~ <br /> <br />~ <br />- ' ~ ~ ~ ~~ ~ ~ <br />~ ~ , ~ ~ ~ v ,~ <br />~ <br />` ~ <br />~ ~ <br />~ . <br /> <br />11 <br />~ • ~ ~ <br /> ~ ... ~~ <br />~ ~~ ~ <br />< <br />~ <br />` ~ <br />~ <br />: ~ <br /> <br />, ~ ~ ~ ~ ~ ~_~ , ~~ <br />~ <br />,~ , , <br />~ ~ '. <br />~ <br />. <br /> <br /> <br />, <br />~ ~~, <br />~ <br />~' ~ ~~ <br /> <br />, <br />~~ _ _ ,~ <br />~ <br />_ ~y~v .~~~~~ <br />~ <br />/ <br /> - <br />~ r <br />_ <br />- •~/j <br />~ i o ° ~`,• _ <br />~~/r ~ <br /> <br />°, ~ ~ ~ _ ~~ <br />- qANK~FAMERI~NS ~' ~ <br />~ <br />~ % <br />- - <br />~ <br />~ ~~ <br /> CC~WIME IAL DISBURSEME <br />Nf A~CT <br /> <br />~K IL <br />~ <br />~~ <br />~= <br />\ ~ <br />,~ <br />~~ <br />,~ <br />~ <br />\ i , <br />;, ,; <br /> <br />„ <br />.-, <br />~ ` <br />~, . <br />~i <br />~ <br />~ i <br /> <br />, <br /> <br />~~~~. . <br />~ <br />~ _ , <br />,; a ~ <br />~ <br />. . y ' '- <br />. , .. , „ - ~~~ ~,,. > , : ~ . _ ~ ~ m a~ ~ <br /> <br />~,~~~ ~~~~ <br />" ~1~ 8 Y3~ IS C6LORED " <br />~ ~ ~a ~tu~,~ae~ ~ ~~t~ ~asu~~ . ~HEGK :N#~, . ; <br />5~~ D~~3875 D0~ .~H ~ A312~~00' 6200019940 ~~ <br />~ <br />~~ <br />vom~.~ti~mioo <br />~ <br />~i'6 2000 ~9940ii' ~:07 i9 23 2B4~: 87655~~~6 2653ii' <br />PLEASE INCLUDE CLAIM NUnn~3FR ~N ei i G~~i-~iaG r~ncn~enn~m~~~.~~ <br />