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„07/17/2009 03:23 7154632931 JENSEN-SUNDQUIST INS PAGE 02/02 <br /> DATE(11"arrm) <br /> PROPERTY LOSS NOTICE 07/27-/2008 <br /> PREV OUSLY <br /> AGENCY PHONE 715-963-2855 MISCELLANEOU6INFO(Olin 6bEMlon moa) DATE OF L083 ANC TIME - AM <br /> 7:30 � _ <br /> _IAIC,-Na.PJt.A•.' .- — 07/7.1/2008 • PM YES X NO, <br /> Jensen-Sundquist Insurance .Agency — --• - --- ” <br /> 3.16 Narliscn Ave POLICY COMPANY ANP_POLICY NUMBER NAIL COOF pow. DATES <br /> p.0. BOX 37 Op; WA1san Mutual 'l;nsuranoc Compan EFF: 05/23/2008 <br /> WI 59890 PROP! - 19950 Exr: 05/23/X09 <br /> Grantsburg, Home Pat:Ho135458 <br /> — ' --- <br /> .. ..__— .._ .._ or: <br /> FAx Na <br /> 115-4133-2931. cO, - <br /> _.. _..._.. ... .,.. .-FLOOD EXP: <br /> EMAIL POLE -'-- ' <br /> __._. <br /> Cops; 670 _ _ _ suecobe, . __ -- "— <br /> _ WIND exP: <br /> AGENC llSTOMER IP:1004967 PC , <br /> INSURED CONTACT X CONTAC7INSUREp <br /> NAME AND A0bRESS DF INSURED 78IRTHNAME AND ADpRESS <br /> Loe,r, SCOCt Loer., Scott.4932 Drummond Rci 4932 Drummond Rd <br /> Mound, MN 55364 Mound, MN 55364 <br /> RE ENCS PHoH€I /C�Nal SINESS NE(NSC, a.Eiq952'472-4390 RESIDENCE PHONE(AIC,No) BUSINESS PHON@ ING,No.Exl) <br /> CELL PHONEC,Nal E.MAr.ADBRESS <br /> 952-7.7.0-3803 612-596-0590 .--- — <br /> _ - - <br /> NAME AND ADDRESS OF SPOUSE IIF APPLICABLE) PATE QF BIRTH CELL PHONE(AlC,NO E-MAIL ADDRE39 <br /> 952-210-3%03 _ <br /> 9932 DTLlmmODd Rd SOC gF.0 MOR FE IN; WHERE TOCONTACT WHEN TO CONTACT <br /> Mound, MN 55364 <br /> LOSS <br /> POLICE OR FIRE PaPT TO WHICH REPorTED <br /> LOCATION Inaured cabin <br /> OP IHSS - <br /> ._— - rHep —' PROBABLE AMOUNT ENTIRE L058 <br /> KINb FIRE LIGKTNINO FLO04 I-, (eapl%In) <br /> OF LOSSTNRFTT MAIL'__ X WIND ..... -. .— <br /> CE6CBIPTH7N OF 605S d DAMAGE(Uee aaP.a.aftea(,Nn000ssery) <br /> Storm came through and winds blew a tree over onto his fi.3h Cleaning shack. It was knorked off the <br /> foundation, cracked the Support boards, and .roof may be damaged. <br /> POLICY INFORMATION <br /> MORTGAGEE Y .. .. .. - _._^. <br /> L NOMORTGAGEe IIS BANK NA ITS SUCCESSCR8 A/OR ASSICN5 PO BOX 7298 c/o U8 EANr, HOME MTG 5pRINGFIELD, OH 45503.-7298 <br /> A.OWELLING B.OTHER STRUCTURES C.PERSONAL e,C.D 6 oddlVarlN coyer oa.Far HPm!o'A'aald 9ecDPr1 II Liability Loiee0.ua^?LORD d.l ... <br /> HOMEOWNER POLICIES SECTION ONLY Complelm for aovotapea A, <br /> rPROPERTY D,L065 OF USE -_OEOUCTIBLES r DESCRIBEADDITIONAL COVERAGES PROVIDED <br /> 4 1 <br /> 913 397 9,641 67 977 19,280 y0U DnI <br /> CQVERAGEA.EXCLUDES WINO HO Form-03SUBJECT TC FORMS(Inacr firm numbors <br /> mmol.�dltUm.dAIAO,ARena4AaduralplmfL_, _ ..... . .-_ ..._ <br /> FIRE,ALLIED LINES•MULTI-PERIL POLICIES(C_"..Iwta only tune RAlml ImPWad In <br /> ITEM SUBJECT OF INSURANCE AMOUNT T.COINS OEDUCTIBLR COVERAGEAND/OR DESCRIPTION OF PROPERTY INSURED <br /> BLDG CNTS - <br /> BLDG CNTS -- _ -- <br /> R7:1 6NT3 <br /> SUBJECT TO PO Mg ---_-- -- -' <br /> (Insart.farm number% <br /> End Millio1 ddtM, <br /> Row a d IducpblA?)_—_—__. ...--_ .. _..-_. <br /> LONE PRE FlRM PIfF IN ELEV FDRM GFJ•1ERAL CONDO <br /> FLOOD BUILDING: OEAUCTIBLE; .r TYPE <br /> ---- DWELLING <br /> POLICY DEDUCTIBLE: POgi FlRM <br /> CONTENTS: -_ <br /> BUILDING DEDUCTIBLE CONTENTS ZONE FORM GENERAL CONDO <br /> TYP <br /> WINO - -- <br /> POLICY E DWELLING _ <br /> RE6) ER INSURANCE(List compadION policy numbma,apyaragn d Policy ammlnvINY ONLY;Previous AupgE56 OF INSURED d WIFE'S MAIDEN NAME <br /> MARKS <br /> Blease contact t.t,einsured as how to proceed w:LLIT the claim. P3-ease CCntara the ].n9ared either at work$ <br /> 612-596-0545 or cWe114 952-210-380j. _. <br /> _........._—_-- PATE A981aNEb... <br /> _. ADJUSTER M <br /> QATA FICDr ADJUSTER <br /> ASSIGNED <br /> REPORTCD BY J__ REPORTED TO ------- 610NATURE OF INSURED ---- SIGN OF PRODUCER <br /> Scott Loer Chervi CO <br /> ACORD 1 (2007101) Page 1 of 2 ©ACORD CORPORATION 199& 07. All ightr reserved. <br /> The ACORD name and loge are registered marks Of ACORD <br />