CERT OF INS.pdfStateRwin State Farm Fire and Casualty Company RENEWAL CERTIFICATE_
PO Box 5000 Fitt HI GE t Cy r''
w",• Dupont, WA98327-5000 11,10meowners PolicyPolicy.� __..- _ ..
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AT 1 H-15- 2969-FB3C H W F
004284 0001
CITY OF EDMONDS
C/O BLDG DIVISION
PERMIT SPECIALIST
ST USE RENEWAL PERMIT#85-3
121 5TH AVE N
EDMONDS WA 98020-3145
-I I -III -III I I II II-I"I III IN I IIII "I III I I I I"II II I' I III II I II II I I
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Insured: CLYBORNE, RONALD A &
MICHELLE C
Location: 9325 OLYMPIC VIEW DR
EDMONDS WA 98020-2397
Loss Settlement Provisions (See Policy)
Al Replacement Cost - Similar Construction
131 Limited Replacement Cost - Coverage B
Forms, Options, and Endorsements
Homeowners Policy
FP-7955.WA
Jewelry and Furs $2,500/$5,000
OPT JF
Silverwaro 'Theft $10,000
OPT SG
Firearms $2,500/$5,000
OPT FA
Earthquake Excl Masonry Veneer
FE-7572.4
Back -Up Dwell/Listed Properly
FE-5432.1
Increase Dwig up to:$166,200
OPT ID
Ordinance/Law 10%/ $83,100
OPT OL
Additional Insured
OPT AI
Identity Restoration Coverage
FE-3301
Amendatory Endorsement
FE-2368
Actual Cash Vlue Endorsement
FE-3650
MAR 29 2018 to MA[l 29 2019
PAID BY SPECIFIED PARTY
Coverages and Limits
Section I
A Dwelling
Dwelling Extension Up To
B Personal Property
C Loss of Use
Deductibles - Section I
Other Losses 1.00%
Except 20% Earthquake
Section II
L Personal Liability
Damage to Property of Others
M Medical Payments to Others
(Each Person)
$831,000
83,100
676,100
Actual Loss
Sustained
8,310
$100,000
5,000
Annual Premium $2,150.00
Earthquake Premium 999.00 (Included)
Sewer & Drain 22.00 (Included)
Premium Reductions
Home Alert Discount 112.00
Home/Auto Discount 480.00
Claim Record Discount 400.00
Inflation Coverage Index: 284.9
Please help us update the data used to determine your premium. Contact your agent with the year each of
your home's utilities (heating/cooling, plumbing, or electrical) and roof were last updated.
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11 .12 Ag t DULIN INS R�NCE A6ENCY INC REB Prepared Ff 6 07 2018
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