FTA01700762 • •-•%." paws rum ore...cull' INSIJKANI:E. vc (This fora is to be completed by the Employee-)-) li fE CONTINENTAL INSURANCE COMPANY KANSAS CITY FIRE' ND MARINE INSURANCE COMPANY FIREMEN'S INSURANCE COMPANY OF NEWARK. NEW JERSEY BOSTON OLD COLONY INSURANCE COMPANY COMMERCIAL INSURANCE COMPANY OF NEWARK. N. J. PHOENIX ASSURAN