��� ^�u�it.-L:��t`' 4, i `' ��`�.,ad�.L���+tFl".�I��'.����'�'� .. , .
<br /> fl:..atG...Yw.-• } i �, � . - y 1- �..� .�*r#".u_;}���'„t�t��� v`
<br /> .:» � `>>S- . _ �. T .? ..- z- - £ 2'.�a L�.y�' � -`' -
<br /> H 4'(YJ i .) (� t ' . -U S`�:;1`5/-t��j ��' ,j j �+ -
<br /> � - .�-;'si 7+ ' ic, �i .�`�- _ �'{1q� Y;"iil��`2Z' .v •F - 't`� "�„i�:Y.;�{. � � T �,
<br /> - ^���� ��`�w"�- �����i����.�Z��t��t� ye �P.�i� _i . o�- ,F i+!^� �4�� -� �.� .
<br /> +�f���r '. c •-a '� ,nL.� .4�: .'s �: _ �y�� .%16i ����'iC'ctr�? 'rN •
<br />.. , T .i.. ...a. ' _ - -'z�' . , . . `i���i�j .,�� _.a'•- _.�.�n�' - - _ •] -
<br /> ..�. ��. +3r +.� .,��, t , � • t � t' ,. , '
<br /> . : � .. �` ..~ - t �at . , � ' . � • � ,. c �.4, ',' ' .
<br />: ,.f • •ec . , . " . . �, - . ` _ µ�'.F
<br /> _4 �,` ` t , 4 's � ' 4 i``
<br /> � �t
<br /> �.,. ,.. . .
<br /> • , ` • ' �?� ���
<br /> , , O ��
<br /> �s.-�-T°�"'`;�_
<br /> � ��� Y��0 Y�V� ����IV��'VdA V@�itlV��E���A\V
<br /> "ti .: �1{Stk8tT1lgR8m°SCa1�Y
<br /> . � � , . . AtxaUnillt0 219-353-0 �
<br /> � .. - ..s �g OS/28/97 '� —
<br /> .' ` '-.k Tpt�qtrt�Un9 pUe 50.297.90 � -
<br /> :.•�-�`'
<br /> � Place of lss�ae:
<br /> ` • _`:. �: � P.O. H03I 328
<br /> ,:,;, ,° , 061dTQQiTIA. MN 55060
<br /> ;� .:' . " LgL�1Ig CpNSTRIIG'£IOi'� DDMC INC 2Y9-353-0
<br /> . . �_. � _;-:f' DBA lOCA1fON OF 1N5!lRED:_--_
<br /> a��o xoRSBSROS pL � pp�p� THpN pf�TED =
<br /> - � ,'�,` ,';,� CREIND ISLAND NP. 68803
<br /> • �'. . ,
<br /> ,, ��.� ;.�� .
<br />: �. �:. .
<br /> . ,..�� . -
<br /> INSUAED'S NAME AND ADORESS
<br /> ' .. .-.._._ . ---� ---�-- - .. �..._. � - • � �ancett�tI�n Tim .. __
<br /> Potl �Pot�cy EtlectSve f @fP� .
<br />=�,u; . , . ,• �71�0 NuRtmEt 41it0 OffiB f.. t�IlC8tl39IW1.,
<br />- . �p�gg�j(�, p� POLICY 107375� �5/21/97 �6/14/97` 1Z:01 a.m.
<br /> , ��... WOgKER a Cpi[(pEfi31�I0N 1�73?53 QS/21/�7' ,�6/14/97 12:01 a.m.
<br /> ,. .
<br /> � ��.�
<br />-._ ;
<br />- . , .. � .._{. - _ __
<br /> - . . . lst/Q6 Ptre ov &tlo4aa 3si�9�•s� PAS4YnUE HA CE
<br /> '.G�/11/97 05/2SI97 io���2 co�aa� PACKAOE POLY�1f RENEi1AL �OtiCV
<br /> � ' M��a/�3/9T 05/21/97 10'1�893 ORitE6�°S CO�IPENSATION REtt�61AL 40LIGV
<br />=_ ; •f�/22/s7 03/01/97 10?�71� C01491ERCIAL PACKAIBE POLICV ADJUSTWEl�T
<br /> REVYSE BUILQEi�''s:R�SK '
<br /> _, � , : [y�/22/97 03/14/97 1073732 C�DERiIia�PT���.POtfCY ADJUS'I�NT
<br /> ' � `�h� ttEVISE BUILDE{RS ii s�L
<br />— ..'':�y�;'j�h REVISE SPECIALN tRAII� �OH7R FLOATEEt
<br />—' . .'�„..,}v�/�2/9�� 031E;��7 107375a CalU4ERCYAI. PAC�{t0E POl.ICY ADJUSTt4�PiT
<br /> _ ,...: � ;t,�Y��: n ,
<br />-�,. �. � !�.,; , . fiEVISE HUgLA� R�SK
<br /> - � �� '��/22/9'7 03/24/97 107�7�2 COtdE�RCIAt PR�IAO� POLICY ADJt1ST�ENY
<br />� .. :.: ��,�,{:•...• ADD � t��AtYOHtS)
<br />— � �°��..; .._ DE�ETE 1 LOCATIOHtS)
<br />— � '� ;75/22/9� 04/10/9T 3073T52 COlq4ERCIAL PACtfABE POLICY ADJUS7MENT . •
<br />- � . � DELET� 3 LOCATIOHtS�
<br /> — � � DELETE 2 VEHIC�E�S)
<br /> ' � ,: (15/22/9T 04/11/97 1073752 CQM�lERCIAL PACKAOE POLICV ADJtiSfi'(�1�£'�
<br />-= • • OBLETE 1 YEHICLElS) ,
<br /> ' � ADD 1 VENICLB�SD
<br /> � ADD AODIT10NA1. IliTEti�'1
<br /> ,. � REVIS� ADDITIOHAL YtiTf�ilS?S
<br /> ��/15/97 O6/lA/97 1073752 COKMERCYAL PACKA3£ POLICY CACICf�bATION
<br /> -- � POLICY CAt1CC�LD
<br />— � 07/15f5i? 06/14/97 1OT3753 ORKER•S CON�''Ci4SATI0ti .' CAtiCG1:l�7fIOH
<br /> POLICY CAIZC4'c�ED
<br />— � .:;:�,;;:;i' .� D�FE[iREO BILLIliO PARTICIPp1I0H FEE
<br /> � � � 10T 752�C0l4�ERCIAL PACKAOE POL 0 ZNSTLMT�S) _`�"- ,
<br />_ • � 107��53 ORKEE3�S C04�P�H9AttOt1 0 aElSTL�4T�S) :_""--
<br /> .: � . --
<br />-_. .' �.••: . mUE•UOOl)RE�EIPT '--�_
<br /> .z...---
<br /> .,.s_��
<br /> �� � � --- .
<br />— . , ..�� , .. . , a; . . :' .�. . . : _ : ... ,
<br /> .. . � , � . . _ . . . ' • . . - _ . _ , '. , . ; .
<br />-�_} . .. . . '. , . . . .' • � . . - . :
<br /> - • , .. • . . . . . ..
<br /> ':�,� �.. . . ... • -. ,. .. ' ' , _ , , , • , : . : , ... -c,:.
<br />
|