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QPR-14-2014 13: 17 From: To:2982859 Page:2/2 <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 /> TOTAL PREMIUM $2,152.00 <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 Ll2.72 A iftLif <br /> � C . <br /> REPRESENTATIVE President Secretary <br /> AGENT 102-067 PHONE (218)236-0161 <br /> John Eidsness Agency <br /> 501 Mama Avenue <br /> Moorhead,MN 56560-0000 <br /> Form No.HO-47C 2 of 2 Stock No.23281 <br />