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Commercial Lines Policy <br /> Common Policy Declarations <br /> ® New Policy No. GP350GL1596 <br /> ❑ Renewal <br /> ❑ Cross—Ref Date: 8/21/2018 <br /> Named Insured and Mailing Address: Name of Insurer/Agreement lTTo. j <br /> Kevin Lehman Certain Underwriters at Lloyds <br /> 1641 Hunters Ridge Lane GP350-18 1 <br /> Centerville,MN 55038 <br /> Coverholder and Mailing Address <br /> Great Plains Brokerage,Inc. <br /> 300 n Cherapa Place <br /> Sioux Falls,SD 57103 <br /> Policy Period: From 9/8/2018 to 9/9/2018 both days at 12:01 am standard time <br /> Form of Business: Z Individual ❑Partnership[] Joint Venture❑ Trust❑ LLC <br /> ❑ Organization❑Non-Profit ❑ Corporation❑ Other <br /> Business Description: Special Event-Block Party <br /> IN RETURN FOR THE PAYMENT OFT E PREMIUM,AND SUBJECT TO ALL THE TEWMS <br /> OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE STATED IN THIS <br /> POLICY, <br /> TIS POLICY CONSISTS S OFT FOLLOWING COVE G TS FOR WHICH A <br /> PREMIUM IS INDICATED. S PREMIUM MAY BE SUBJECT TOADJUSTMENT. <br /> COVERAGE PREMILTM <br /> Commercial General Liability 300 <br /> Policy Fee 15 <br /> SIL Tax $ 11.25 <br /> 'Stamp Tax $0.15 <br /> Total:$386.40 <br /> Forms and Endorsements made a part of this policy at time of issue: <br /> See Schedule of Forms and Endorsements <br /> Countersigned: Sioux Falls,SD <br /> ......... rcniu�u mcg rw, ¢�n rci lhm��+hrti�tlln�a�ri�ac at 11 r]nu cra�u�l;�ii�r� <br /> THIS COMMON POLICY DECLARATIONS AND THE SUPPLEMENTAL DECLARATIONS,TOGETHER WITH <br /> THE COMMON POLICY CONDITION-S,COVERAGE FORMS AND ENDORSEMENTS COMPLETE THE ABOVE NUMBER <br /> POLICY <br /> GP350(6.11)BRIT Includes copyrighted material of the Insurance Semites Office,Inc.with its permission <br />