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txhibi ~- ''~ `' <br />TFIE COMMUNITY LIFE INSURANCE COMPANY <br />Box 10, 6740 North High Street <br />Worthington, Ohio 43085 <br />REQUEST FOR CHANGE <br />'olicyholderrDiayfield Village ~ PoIIcyN 61305-901 <br />,ddress 6621 Wilson Mills Road _ _ <br />Mayfield, Ohio 44143 RequestedEffectlveDate <br />;ity 8 State <br />;ip <br />L ~ <br />The Policyholder requests that the Group Policy, Certificate of Insurance and/or Group Application be changed es follows: <br />f~20 AD&D coverage should read: <br />non-occupational <br />~ ~ <br />,.. ` ~ <br />It is agreed that no change shall become effective until this request has been approved by Community Life at its Home Office, <br />subject to payment of any additional premium due. <br />THE COMMUNITY LIFE INSURANCE COMPANY <br />By / ~ Approvod by <br />T(tle Mayo tAay~eli~a~g°seenmtive) Date <br />Yellow-PH Copy <br />CLIC 306.OG6.1081 (Return All Copies) Plnk-AG Copy <br />