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<br />POLICY NUMBER: <br />NEW POLICY <br /> <br />COMMON POLICY DECLARATIONS <br /> <br />MEMORANDUM COPY <br />D <br /> <br />CM28569 <br /> <br />~. <br /> <br />NORTH STAR MUTUAL <br />INSURANC~ COMPANY <br />BOX 48 COTTONWOOD, MINNESOTA 56229-0048 <br /> <br />NAMED INSURED AND MAILING ADDRESS <br /> <br />CENTER-MART LLC <br /> <br />1801 MAIN ST <br />CENTERVILLE MN <br /> <br />55038 <br /> <br />168 <br /> <br />AGENT AND ADDRESS <br /> <br />ALL CITY AGENCY <br />1287 MOUND TRAIL <br />CENTERVILLE MN 55038 <br /> <br />. (651)' 481-8744 <br /> <br />POLICY PERIOD: FROM 10/04/05 TO 10/04/06 AT 12:01 A.M. STANDARD <br />TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. <br /> <br />This replaces all previously issued policy declarations, if any. In return for the payment of the <br />premium and subject to all- the terms of this policy, weC3gree with you to provide the insurance as <br />stated in this policy during the policy period shown above. <br /> <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS <br />INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />COMMERCIAL PROPERTY COVERAGE PART ..........:....... -:........ ~.... -$'2',635.00 <br />COMMERCIAL GENERAL L1ABIUTY COVERAGE PART . . . . . . . . . . . . . . . . . . . . .. . $ 844 .00 <br />CERTIFIED TERRORISM COVERAGE (SEE DISCLOSURE NOTICE) . . . . . . . . . . . . . $ 0 .00 <br />TOTAL ANNUAL PREMIUM.. $ 3, 479 ~ 00 <br />PREMIUM AUDIT PERIOD: ANNUAL <br /> <br />BILL TO: INSURED <br /> <br />(THIS IS NOT A BILL; STATEMENT WILL FOLLOW) <br /> <br />Your policy is subject to the forms/endorsements"'tisted below-any new or revised <br />forms/endorsements are attached and now apply. (If this is a renewal certificate or a revision", only <br />the new or revised forms/endorsements are attached.) <br /> <br />IL0017(11-98) <br />CP0010(10-90) <br />IL0935(07-02) <br />CP1218(10-90) <br />CF1181(05-91) <br />CF-846(08-00) <br />CG2147(07-98) <br />IL0021(11-94) <br /> <br />CF1332(10-02) <br />CP0090(07-88) <br />CF1736(12-03) <br />CPI030(10-90) <br />CF1335(05-93) <br />CF-962(03-89) <br />CG2160(09-98) <br />Il0245(09-03) <br /> <br />CF-1752(12-03) <br />CP0157(07-98) <br />CP0015(07-88) <br />CP1440(07-88) <br />CF1403(04-94) <br />CGOOOl(11-88) <br />CG2167(04-02) <br />CG2104(11-85) <br /> <br />CF-1806 (1'-05) <br />IL0003(07-02) <br />CP0032(10-90) <br />CF1821(02-05) <br />CF1408(01-94) <br />CG0057(09-99) <br />CG2681(11-02) <br /> <br />COUNTERSIGNED: 10/14/05 <br /> <br />BY <br /> <br />(OUR AUTHORIZED REPRESENTATIVE) <br /> <br />2 <br /> <br />~j <br /> <br />CONTINUED ON REVERSE SIDE <br />