HomeMy WebLinkAbout109 Princess Way_20180209124021c
1-
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INSURANCE COMPANY
RB 72't530
381 -0064993171
BOB HART INSURANCE INC
PO BOX 1240
GRANTS PASS OR 97528-010r
CITY OF CENTRAL POINT
155 S zND ST
CENTRAL POINT OR 97502-2209
381 -0064993't71-04
Form737375 O4lOs
36
I 3059
Namo and Address of Add¡tional Named lnsured:
CITY OF CENTRAL POINT
155 S 2ND ST
CENTRAL POINT OR 97502-2209
lnsurlng Agreement
The second paragraph is changed to include:
You, your and yours also means the additional person(s)
named on this endorsement.
527405/99
ADDITIONAL NAMED INSURED
5274 05/99
All other provisions of your policy apply.
13060
IN6URANCECOMPANY
Hmo offico
5600 B€och Tree Lane
P.O. Box 2450
Caledonia, Michigan 499 t 6
POLICY NUMBER: 381-0064993171-04
RENEWAL OF: 381-0064993171-03
POLTCY PERTOD BEGTNNTNG 04/27 /06 ENDTNG 04/27 /O7
THOHAS SZCZESNIAK
SUSAN SZCZESNIAK
109 PRINCESS WAY
CENTRAL POINT OR 97502-1850
BOB HART INSURANCE INC
P0 BOX 1240
GRANTS PASS OR 97528_OTOI
FOREMOST CLASSIC CL I{OMEOWNERS
DECLARATIONS PAGE
L2z0L A.ll. STANDARD TII'ÍE
AGENCY GODE:
364000016
TELEPHONE:
(541) 479-s52r
GOvERAGES: Coverage is provided only where a specific premium charge is shown below or where shown as
included without specific charge either below or in your policy. Detailed descriptions and any limitations will be
found in your policy.
PREMISES
DESCRIPTION
109 PRINCESS WAY
CENTRAL POINT OR 97502-1850
CONSTRUCTION
FAMILIES:
OGCUPANCY:
HYDRANT:
FIRE DEPT.:
FRAI{E
1
PRI}IARY
lfITHrN 1,000 FEET
WITHIN 5 I,ÍILES
TERRITORY:
PROT- CLASS:
RESP. FIRE DEPT.:
COUNTY:
A
3
JACKSON
1960
HO
YR. BUILT:
FORM:
LOAN NO.: 000803496301lD
CITIilORTGAGE INC
ISAOA
PO BOX 7706
SPRINGFIELD OH 4550L-7706
A. DWELLINGB. OTHER STRUCTURESC. PERSONAL PROPERÎYD. ADDITIONAL LIVING EXPENSE
I
$
$
$
$229,
22,
7r4,
753
975
877
95r
717. 00
INCLUDED
INCLUDED
INCLUDED45
SECTION I LOSSES ARE SUBJECT TO A DEDUCTIBLE OF: 95,000 ALL PERILS
poricy Number: 381 -0064ee3171 -o4 ADDITIONAL INTEREST COPY
13061
Form Boooo o4l93 PAGE I
$
$
E
F
COMP PERSONAL LIABILITY
MEDICAL PAYMENTS
3 00
2
OOO EA
OOO EA
ACCIDENT
PERSON
INCLUDED
INCLUDED
5257
6978
5510
5264
3434
5274
05 lee
03/00
05/02
05/e9
09 /96
os/e9
HOMEOWNERS POLICY _ CLASSIC CL
REQUIRED CHANGE - OREGON
EXCEPTION TO COVERAGE - UOLD
EARTHQUAKE COVERAGE
REPLACEMENT COST PERSONAL PROPERTY
ADDITIONAL NAMED INSURED
$
$
138. 00
125.00
INCLUDED
LOSS HISTORY SURCHARGE
MINII{UM EARNED PREUIUU $1OO
THIS DECLARATIONS PAGE WITH YOUR FOREMOST POLICY PROVISIONS AND ANY ENDORSEMENTS ISSUED TO
FORM A PART THEREOF COMPLETES THE ABOVE NUMBERED POLICY.
Processefl3 February 27, 2006
l.
$
LOCATION # I Annual Premium $
17 4.O0
1 , 154.00
Por¡cy Number: 381 -0064es3171 -o4 ADDITIONAL INTEREST COPY Form 8oo0o o4l93 PAGE 2