**INSURANCE COMPANY OF NORTH AMERICA**

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**NOTICE OF CHANGE**

The undersigned hereby provides notice to the insured that the policy number **[Policy Number]** has been changed to **[New Policy Number]**.

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Nothing herein contained shall vary, alter or extend any provision or condition of the policy other than as above stated.

| Effective Date | at the honor specified in the policy. |
|---------------|--------------------------------------|
| Issued to     | [Insured's Name]                     |

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Authorized Agent

Not valid unless countersigned by a duly authorized agent of the INSURANCE COMPANY OF NORTH AMERICA

C - 1762A 175M 1-70 Pid. in U.S.A.

**Charles K. [Last Name]**