DM-2012-00387_0001.tif 09/10/2012 10 :43 4024264048 C &K ENTERP /HART MCMT PAGE 01/01
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¢` I R.O. BOX81529 LINCOLN, NEBRASKA 68509
DE CLARATION S
DWELLING PROPERTY CANCELLATION PAGE 1
PRICY NUMBER FU E NUMBER EFF€OTl E DATE BILLS TD
HENNIN AGENOY AND AGB T
uo opr vk
DP798272 444241 02/24/I2 INSURED 479 -023 BLAIR INSURANCE AAGENCY GS, RENEE S.
(402) 426 -4888
NAMEDINSURm(47 HARTVIGSEN, KEITH & CAROL
940 N 28TH AVE
BLAIR NE 68008
i
THIS POLICY COVERS FORTHETERM INDICATED BELOW AND WI IBS RENEWE EACH TERM THEREAFTER
TERM POLICY FORM
(MONTHS)
12 3
INSURANCE ATTACHES ONLY TO THOSE COVERA ANWOR IT EMS OEBCftIBED IN THE OSCLARA71ONS AT THE LOCATION(EA iNDl4ATEC FOR WHICH AN AMOUNT I5 SHOWN IN THE
SPACE PROVIDED, AND NOT EXCEEDING SAID AMOUNT; AND SUBJEOTTO THE PERILS, DEFINITIONS, TERMS, PROVISIONS, AID CONDITIONS AS BET FORTH IN THE POLICY,
AMOUNT
I
IDENTIFICATION! LOCATIONS & COVERAGES 1 ITEMS i MORTGAGEE � DEDU"BLE i INSURANCE O
� PREMIUM
CODE ITEM i
LOt ATION 1 1414 GRANT ST
BLAIR NE 68008
0101 -001 A DWELLING FRAME (2 FAMILY) 500 75,100 $306.00 -
INFLATION ADJUSTMENT END.
0232 B OTHER STRUCTURES 500 7,510 INCL
500 2,000 INCL
0340 C PERSONAL PROPERTY
0400 D LOSS OF USE 500 7, 510 INCL
0610 - 002 BODILY INJURY 65147 NONE 300,000 $12.00 -
OLT ENDORSEMENT
0620 -008 PROPERTY DAMAGE 65141 NONE 100,000 $1.00 -
OLT ENDORSEMENT NONE 1,000 $5.00-
0640 -004 MEDICAL PAYMENTS 6514?
OLT ENDORSEMENT $7.00 -
0600 -005 CELT MINIMUM PREMIUM ADJUSTMENT
OLT ENDORSEMENT
0101 -006 DWELLING
MISCELLANEOUS ENDORSEMENT
SPECIAL WIND AND HAIL DEDUCTIBLE APPLIES - $1,000 DEDUCTIBLE IF THE DWELLING (OR COV. B OTHER
STRUCTURE IF THERE IS NO DWELLING INSURED AT THIS LOCATION) ROOF SURFACE IS ASPHALT
COMPOSITION, $2,000 DEDUCTIBLE IF THE ROOF SURFACE IS OTHER THAN ASPHALT COMPOSITION
TOTAL TERM PREMIUM $3J1.Oa-
I
SUBJECT TO THE FOLLOWING ENDORSEMENTS
11203 -0411 DP -3 SPECIAL FORM POLICY
20024 -0108 TERRORXSM ENDORSEMENT COVERAGE
21293 -0703 LIMITED FUNGI (INCL MOLD) END.
20007 -0704 GENERAL POLICY CONDITIONS END.
21268- 0707 DWELLING PROPERTY AMEND END
21215 -0608 INFLATION ADJUSTMENT END.
2222 -1205 OLT ENDORSEMENT
2004 -0487 MISCELLANEOUS ENDORSEMENT
21274 -0812 SPECIAL WIND & HAIL DEDUCTIBLE
12150
POLICY CANCELLED AS REQUESTED EFFECTIVE 07/31/12
PREMIUM ADJUSTMENT $189.00 CR
10101707 08/30/12
I
I