Forms and Endorsements · 9/8/2013 · 2 2 2 Stalworth Insurance Company Homeowners Policy...

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Forms and Endorsements

2 Homeowners Liability Coverage, 2nd Edition

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Stalworth Insurance Company Homeowners Policy

Declarations

Policy Number: HO 927-168-35

Policy Period: From: August 9, 2013 To : August 9, 2014 Months: 1212:01 a.m. Standard Time at the residence premises

Named Insured and Mailing Address:Leah Bachman11491 Bretson RoadElysium, Anystate 01001

The residence premises covered by this policy is located at the above address unless otherwise stated.

__________________________________________________________________________________________

Coverage is provided where a premium or limit of liability is shown for the coverage.

DEDUCTIBLE – Section I: $ 500

Section II: Other insured locations:

Mortgagee/Lienholder (Name and Address)Pikeville Mortgage CompanyP.O. Box 1250Elysium, Anystate 01001

CountersignatureTitle of Countersigner

Date: 7-25-13 Agency: Davidson Agency

PREMIUMLIMIT OF LIABILITYSECTION I COVERAGES

$ A. Dwelling 100,000 $ 915$ B. Other Structures 10,000 $ (incl.)$ C. Personal Property 50,000 $ (incl.)$ D. Loss of Use 30,000 $ (incl.)

SECTION II COVERAGES

E. Personal Liability,$

$

each occurrence 300,000 $ 10F. Medical Payments to Others, 2,000 $

$

5each person

Total Premium for all endorsements listed below 47

TOTAL POLICY PREMIUM $ 977

Forms and endorsements made part of this policy at the time of issue:

PremiumName of FormEdition DateForm NumberHO 0003 $ —HO 0461 $ 12HO 0454 $ 35HO $HO $

Homeowners 3 Special FormScheduled Personal PropertyEarthquake

05 1105 1105 11

3Forms and Endorsements

Forms and Endorsements · 9/8/2013 · 2 2 2 Stalworth Insurance Company Homeowners Policy...

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