# CANCELLED

**DATE:** 5-21-73  
**BORDEREAU NO.:** 130-73  

**PRO RATA:** ☐  
**SHORT RATE:** ☐  
**NOT TAKEN:** ☐  
**NOT RENEWED:** ☐  
**REWRITTEN:** ☐  

**REINSTATED**

**DATE:**  
**BORDEREAU NO.:**  

**PREM. ADJ. BY:**  
**DATE:**  

**DIV. ADJ. BY:**  
**DATE:**