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<br />HOMEOWNERS POLICY <br /> <br />2 YIF <br /> <br />POLICY NUMBER: H279690 <br />REVISION EFFECTIVE 11/12/07 <br /> <br />INSUREDS COPY <br /> <br />POLICY PERIOD: FROM 11/20/07 TO 11/20/08 <br />12:01 AM STANDARD TIME <br />- DECLARATIONS - <br /> <br />[~ <br /> <br />NORTH STAR MUTUAL <br />INSURANCE COMPANY <br />BOX 48 COTTONWOOD, MINNESOTA 56229-0048 <br /> <br />NAMED INSURED AND ADDRESS: <br /> <br />701-838-9624 <br /> <br />AGENT AND ADDRESS: (701) 843-7524 <br /> <br />HILARY GIETZEN <br />4600 HWY 52 SLOT 17 <br />MINOT NO 58701 <br /> <br />1178 SECURITY INS & INVEST CENTER <br />700 ASH AVENUE <br />P.O. BOX A <br />NEW SALEM ND 58563 <br /> <br />This replaces all previously issued policy declarations, if any. This policy applies only to accidents, occurrences or losses <br />which happen during the policy period shown above. This policy applies only to those coverages below for which a limit or <br />premium charge is shown. Our limit for each coverage shall not be more than the amount stated for such coverage, subject <br />to all of the terms of this policy. <br /> <br />CREDIT HISTORY OR CREDIT RATING WAS USED TO DETERMINE THE PREMIUM OF THIS POLICY. <br />I PROPE <br />COVERA <br /> <br />~MIT <br />UERSONAL <br />LIABILITY <br />COVERAGE <br /> <br />RTY A RESIDENCE B RELATED PRIVATE C PERSONAL o ADDITIONAL <br />GES STRUCTURES PROPERTY LMNG EXPENSE <br /> ACTUAL LOSS SUS- <br /> $131,500 $13,150 $ 78,900 TAINED IN 12 MTHS I <br /> ~ - <br /> <br />L PERSONAL LIABILITY <br />LIMIT $ 500,000 (EACH OCCURRENCE) <br /> <br />M MEDICAL PAYMENTS TO OTHERS <br />LIMIT $5,000 (EACH PERSON) <br /> <br />~~ <br />I <br />I <br /> <br />$ 5.000 DEDUCTIBLE <br /> <br />PROT CLASS: P; 1 FAMILY FRAME; YOC: 1977 ; ROOF AGE: 1999 <br />DESCRIBED LOCATION: COUNTY OF WARD (1010) <br />4600 HWY 52 SLOT 17 MINOT NO 58701 <br />PERSONAL LIABILITY & MEDICAL PAYMENTS EXTEND TO A SEASONAL DWELLING LOCATED AT <br />731852 AVE N HARWOOD NO; VACANT LAND LOCATED: SEC 18-140-49 CASS CO MN W/3.55 <br />ACRES <br /> <br />Your policy is subject to the forms/endorsements listed below. Any new or revised forms/endorsements are <br />attaclied and now apply. Current policy forms are available on request. <br />PREMIUM <br />428.00 <br /> <br />NS""3 <br />NS-131H <br />CF-1572 <br />CF-1857 <br />NS-100 <br /> <br />- (04-9tr) SPECIAL FORM <br />(08-06) AMENDMENT OF POLICY TERMS - HOMEOWNERS <br />(04-98) CALENDAR DATE OR TIME FAILURE EXCLUSION <br />(08-06) ORDINANCE OR LAW - BASIC COVERAGE <br />(03-02) INLAND MARINE GENERAL TERMS <br />INCREASED LIMITS LIABILITY/MEDICAL PAYMENTS <br />NS-55 (04-98) REPLACEMENT VALUE LOSS SETTLEMENT TERMS <br />NS-175 (05-91) PERSONAL ARTICLES COVERAGE <br />NS-Z08 (04-98) BACK UP OF SEWER, DRAIN OR SUMP SYSTEM <br />NS-Z786 (08-06) IDENTITY FRAUD EXPENSE <br />YOUR PREMIUM HAS BEEN REDUCED BY THE FOLLOWING DISCOUNTS: <br />ML-216 (Z.O ) PROTECTIVE DEVICES DISCOUNT <br />HIGHER DEDUCTIBLE DISCOUNT <br />INSURANCE SCORE FACTOR DISCOUNT <br /> <br />INCL. <br />INCL. <br />INCL. <br />48.00 <br />43.00 <br />48.00 <br />55.00 <br />INCL. <br /> <br />2% INCL. <br />32% INCL. <br />12% INCL. <br /> <br />TOTAL ANNUAL PREMIUM 622.00# <br />ADJUSTED PREMIUM 4.00 <br />DIRECT BILL INSURED (THIS IS NOT A BILL; STA TEMENT WILL FOLLOW) <br />#-PREMIUM CHARGED INDICATES NO WOODBURNING/SOLlD FUEL EQUIPMENT <br /> <br />PROCESS DATE: 11/19/07 <br /> <br />4 <br /> <br />CONTINUED ON REVERSE SIDE <br />