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APR-14-2014 13:17 From: To:2982859 Paee:1/2 <br /> DECLARATIONS <br /> NORTH DAKOTA HOMEOWNERS POLICY-GOLD STAR SPECIAL DELUXE FORM(ED 06/94)NC <br /> NON-ASSESSABLE POLICY ISSUED BY AMERICAN FAMILY MUTUAL INSURANCE COMPANI <br /> A MEMBER OF THE AMERICAN FAMILY INSURANCE GROUP, MADISON,W <br /> PLEASE READ YOUR POLICY <br /> POLICY NUMBER 33P7-0713-01 <br /> MORTGAGEE <br /> REFERENCE NUMBER:228454 <br /> GATE CITY BANK <br /> ITS SUCCESSORS AND/OR ASSIGNS <br /> PO BOX 2847 <br /> FARGO,ND 58108-2847 <br /> NAMED INSURED <br /> SMITH,COREY L&SHERRI M EFFECTIVE <br /> 4978 KLITZKE DR FROM 3/4/2014 TO 12/8/2014 <br /> HORACE,ND 58047-9726 ACCT 504-726-359-59 <br /> COVERAGES AND LIMITS PROVIDED <br /> 001 FAMILY FRAME STUCCO DWELLING IN TOWN CLASS 9 <br /> SECTION I LIMITS <br /> DWFT.r,ING $250,200 <br /> PERSONAL PROPERTY ON PREMISES $187,700 <br /> PERSONAL PROPERTY OFF PREMISES 100%SUBJECT TO POLICY LIMlTATIO1 <br /> LOSS OF USE-ACTUAL LOSS SUSTAINED WITHIN 12 MONTHS OF THE LOSS $1,000 <br /> DEDUCTIBLE AMOUNT-ALL PERIL <br /> SECTION II <br /> PERSONAL LIABILITY $500,000 <br /> MEDICAL EXPENSE $1,000 <br /> ADDITIONAL PROTECTION/ENDORSEMENTS <br /> OPTION 2-EXTENDED COVERAGE ON JEWELRY,WATCHES AND FURS <br /> OPTION 1.4-PERSONAL PROPERTY REPLACEMENT COVERAGE <br /> OPTION 13 -OTHER STRUCTURES <br /> SCHED PLEASURE HORSE&EQUIP COV-(END 407 ED 6/94)-2 HORSES <br /> ADDITIONAL PROTECTION SCHEDULE(END 436 ED 3/01) <br /> /c LIABILITY COVERAGE FOR FARMLAND RENTED TO OTHERS (END 506 ED 6/94) <br /> COMPUTER RELATED&ELECTRON PROB EXCL(END.581 ED. 10/98) <br /> FUNGI OR BACTERIA EXCLUSION(END 595 ED 6/02) <br /> GOLD STAR HOMEOWNERS AMENDATORY(END 587 ED 10/99) <br /> THIS POLICY INCLUDES INCREASED BUILDING LIMIT COVERAGE UP TO 120%OF THE <br /> DWELLING LIMIT SHOWN ABOVE,SUBJECT TO POLICY PROVISIONS. <br /> CUSTOMER LONGEVITY DISCOUNT/CLAIM FREE DISCOUNT HAVE BEEN APPLIED <br /> HOME&AUTO DISCOUNT HAS BEEN APPLIED <br /> HOME AND UMBRELLA DISCOUNT HAS BEEN APPLIED <br /> LATEST BUILDING COST INDEX IS 211 <br /> Declarations effective on the date shown above.These declarations form a part of this policy and replace all other <br /> declarations which may have been issued previously for this policy. If these declarations are accompanied by a new <br /> policy,the policy replaces any which may have been issued before with the same policy number. <br /> AUTHORIZED �—�- <br /> REPRESENTATIVE President secretary <br /> AGENT 102-067 PHONE (218)236-0161 <br /> John Eidsness Agency <br /> 501 Mai Avenue <br /> Moorhead,MN 56560-0000 <br /> Form No.HO-47C 1 of 2 Stock No.23281 <br />