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, _ <br /> Form \o. 14. � <br /> pPllcnli \o.�-, /� <br /> ,,,.. .�!�`� -- _�' �.... .. <br /> ..... .. � �,CG........ Strcet. <br /> � <br /> ��;......�� <br /> Fvrrr�l..................�i....... .......... 190,? <br /> , � TO THIi Sl?PGRItiT13\D13ST OI� TIIIi f:1'I;RI:TT \FATTR C� \IP,1T'1': /. <br /> 1 I�pr L�l�i�ppl)' fnr the nro of �c:,tcr in necnrJnnce w�ith thc rul�•�; nnd r:�gnlniiouR of thc Iiccrelt R'ntcr Comp;my,nn�l reqn�,Pt <br /> � I h <br /> iJIRL.O� (.�..InNi tnP bo Insorlyd in ihc d� �t Ihc pinrr ah/y� � s I. <br /> �. Thr',ph� �I�rr n•ho will do mp �corl< Is..� %f,(,U�-[J—�� <br /> � . ... .. . .. � .. <br /> .......... <br /> . y, . . .............. <br /> Tirr ntcnrr af tLe premi.^,ex is... ........... ,;�p/��C <br /> . ... .... ..... ............ <br /> � .................................... .. <br /> � .......... .. <br /> 1'hc nRrntlx............................. �,/ <br /> ...................�.0 ............. <br /> .................................... . <br /> . ... ......... <br /> � 7'hr Irnnutfe................ � <br /> ............ ..... <br /> .................. ........... <br /> � .................................... <br /> .............. <br /> , 7'hr wn�rr rent shnNd bi� ehnrKeii in............................:d <br /> ............ .................... <br /> ................ .............. <br /> � � <br /> � (Ser Other SIde1. Si�;ned..��]..�;z;�l,!-�_�tr�� [t�� <br /> - ............... .............. <br /> ApP11raN. <br />