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PART B DECLARATION PAS'= <br />tdwest VLutuai <br />Insuring Midwest Values <br />Since 1891 <br />MIDWEST FAMILY MUTUAI <br />INSURANCE COMPANY <br />P.O. BOX 9425 Minneapolis, MN 55440-9425 <br />GARAGE BUS INESSOWNER= <br />Renewal Coverage Summary <br /><: . <br />ROCICYLIFT 'NUMBER : FROM POLICY PERIOD ` TO , <br />GRMN0560025417 08/17/10 108/17/11 12 01 AM STANDARD TIME <br />.: :NAMEDANSORED; AND :.-. DD:RESS ` : - AGENT.:... . <br />LAWRENCE JOSEPH FERBER <br />DBA: LARRY'S AUTO BODY <br />17441 BAUGH ST <br />RAMSEY, MN 55303 <br />ASPEN AGENCY LLC <br />2669 COON RAPIDS BLVD NW <br />COON RAPIDS, MN 55433 <br />Phone: (763) 755-7000 <br />'X' IF SUPPLEMENTAL DECLARATION IX SUPPLEMENTAL DECLARATION <br />Business Description: Form of Business: <br />Auto Body or Paint Shops Individual <br />DB <br />19 <br />In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in <br />this policy. <br />DESCRIBED PREMISES <br />Premises No. Bldg. No. Location Mortgage Holder Name and Address <br />I Forms Applicable: Special <br />SEE ATTACHED SUPPLEMENTAL DECLARATIONS SEE ATTACHED SCHEDULE <br />PROPERTY I PREM. NO. I BLDG. NO. I PREM. NO. I BLDG. NO. I PREM. NO. I BLDG. NO. <br />SEE ATTACHED SUPPLEMENTAL DECLARATIONS <br />Deductible $ SEE ATTACHED SUPPLEMENTAL DECLARATIONS <br />OPTIONAL COVERAGES <br />SEE ATTACHED SUPPLEMENTAL DECLARATIONS <br />LIABILITY AND MEDICAL PAYMENTS <br />Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual <br />period. Please refer to paragraph D.4. of the Businessowners Liability Coverage Form. <br />Liability $100 DEDUCTIBLE COMPLETED OPERATIONS <br />Medical Expense <br />Fire Legal Liability <br />Limits of Insurance <br />$1,000,000 per accident/ $2,000,000 annual aggregate, <br />$5,000 per person <br />$150,000 any one fire or explosion <br />TOTAL PREMIUM $1,842.00 <br />FORMS AND ENDORSEMENTS: SEE ATTACHED SCHEDULE <br />SYMBOL 30 APPLIES TO GARAGE LIABILITY (See CA0005) <br />THESE DECLARATIONS, TOGETHER WITH THE COVERAGE FORM(S), COMMON POLICY CONDITIONS AND FORMS <br />AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. <br />Includes copyright material of Insurance Service Office Inc., with its permission. Copyright Insurance Service Inc., 1984, 1985 DATE 07/20/2010 <br />PAGE 1 <br />