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<br />C-1 <br />, . I <br />~.~ . ,~ <br /> <br />Allied <br />Insurance <br /> <br />AMCO INSURANCE COMPANY <br />1100 LOCUST ST DEPT 110DES MOINES IA 50391-1100 <br /> <br />22 23491 <br />NEW BUSINESS <br /> <br />A Nationwide@lCompany <br />On Your Side'" <br /> <br />PREMIER BUSINESSOWNERS POLICY <br /> <br />PREMIER RETAIL <br />COMMON DECLARATIONS <br /> <br />Policy Number: ACP BPR 7101568853 <br /> <br />Named Insured: CENTER MART LLC <br />BUECHLER, CARL <br />Mailing Address: 1801 MAIN ST <br />CENTERVILLE. MN 55038 <br />Agency: ALL COUNTY AGENCY INC <br />Address: FOREST LAKE MN 55025 <br />Agency Phone Number: (651)484-1661 <br /> <br />Policy Period: Effective From 05-18-04 To 05-18-05 <br />12:01 AM Standard Time at your principal place of business. <br /> <br />Form of your business entity: CORPORATION <br /> <br />Description of your business: CONVENIENCE STORE <br /> <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THIS POLICY, <br />WE AGREE TO PROVIDE THE INSURANCE STATED IN THIS POLICY. <br /> <br />CONTINUATION PROVISION: If we offer to continue your coverage and you or your representative do not accept, <br />this policy will automatically terminate on the expiration date of the current policy period stated above. Failure to <br />pay the required premium when due shall mean that you have not accepted our offer to continue your coverage. <br />This policy will terminate sooner if any portion of the current policy period premium is not paid when due. <br /> <br />( <br /> <br />PREMIUM FOR CERTIFIED ACTS OF TERRORISM <br /> <br />$ <br /> <br />0.00 <br /> <br />u tersignat e Date <br /> <br />These Common Policy Declarations, together with the Common Policy Co.{ditions, Coverage Form Declaration <br />Coverage Forms and any endorsements issued to form a part thereof, complete the Policy numbered above. <br /> <br />NONE <br /> <br />ENTRY DATE <br /> <br />06-01-04 <br /> <br /> <br />547.00 <br /> <br />Previous Policy Number <br /> <br />PB 81 00 (01-01) <br /> <br />Page 1 of 2 <br /> <br />DIRECT BILL LKBO <br /> <br />BS <br /> <br />INSURED COPY <br /> <br />UID <br /> <br />43 <br /> <br />71 00103 <br />