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<br />HOMEOWNERS POLICY -- RENEWAL CERTIFICATE <br /> <br />POLICY NUMBER: H279690 PLEASE RETAIN THIS RENEWAL CERTIFICATE INSUREDS COpy <br />..-- WITH YOUR ORIGINAL POLlCIYl! <br /> <br />POLlCYPERIOD:FROM 11/20/2008TO 11/20/2009 .~orth Star <br />12:01 AM STANDARD TIME MUTUAL IN SU RANCE COM PANY <br />_ DECLARATIONS - . Box 48 Cottonwood, rvlinnesota 56229 <br /> <br />3YlF <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 />In consideration of the payment of the premium specified, the policy designated above is renewed for the indicated period. <br />Insurance is provided only with respect to the coverages and limits shown below. The terms and conditions of the policy are <br />stated in the original policy, unless changed by formes) and/or endorsement(s) listed on this renewal certificate. <br /> <br />CREDIT HISTORY OR CREDIT RATING WAS USED TO DETERMINE THE PREMIUM OF THIS POLICY. <br /> <br />I PROPERTY A RESIDENCE B RELATED PRIVATE C PERSONAL D ADDITIONAL <br />! COVERAGES STRUCTURES PROPERTY LIVING EXPE <br />, -.--..--.- <br />\"-------.--. <br /> ACTUAL LOS <br />j LIMIT $135,500 $13,550 $81,300 I TAINED IN 12 <br /> , <br /> <br />---_.,---_._~ --j <br /> <br />NSE I <br /> <br />______.~__,_. _I <br />S SUS- <br />MTHS <br /> <br />, <br />t:::::::=. <br />i PERSONAL r L PERSONAL LIABILITY <br />l~~~~~~__I______!:~~IT $ 500,000 (EACH OCCURRENCE) <br /> <br />..i5.000 DEDUCTIBLE <br /> <br />--.-'--,::::-.1 <br /> <br />, <br />M MEDICAL PAYMENTS TO OTHERS i <br />I <br />LIMIT $5,000 (EACH PERSON) i <br />----------. .-------.---..----.. j <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 ND 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 />407.00 <br /> <br />(04-98) SPECIAL FORM <br />(01-08) AMENDMENT OF POLICY TERMS - HOMEOWNERS (ND) <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-208 (04-98) BACK UP OF SEWER, DRAIN OR SUMP SYSTEM <br />NS-2786 (08-06) IDENTITY FRAUD EXPENSE <br />YOUR PREMIUM HAS BEEN REDUCED BY THE FOLLOWING DISCOUNTS: <br />ML-216 (2.0 ) PROTECTIVE DEVICES DISCOUNT <br />HIGHER DEDUCTIBLE DISCOUNT <br />VALUED CUSTOMER DISCOUNT <br />INSURANCE SCORE FACTOR DISCOUNT <br /> <br />NS-3 <br />NS-131H <br />CF-1572 <br />CF-1857 <br />NS-100 <br /> <br />INCL. <br />INCL. <br />INCL. <br />47.00 <br />41. 00 <br />47.00 <br />54.00 <br />INCL. <br /> <br />2% INCL. <br />32% INCL. <br />2% INCL. <br />12% INCL. <br /> <br />TOTAL ANNUAL PREMIUM <br /> <br />596.00# <br /> <br />PROCESS DATE: 1012012008 <br /> <br />5 <br /> <br />CONTINUED ON REVERSE SIDE <br />