DATE (MM/DD/YYYY)

CERTIFICATE OF PROPERTY INSURANCE 01/10/2025

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
PRODUCER CONTACT Grace
NAME:
Renee Forde State Farm PHONE FAX
(A/C, No, Ext): 7012802811 (A/C, No):
E-MAIL
ADDRESS:
PRODUCER
CUSTOMER ID:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A :

Daniel Nelson INSURER B :

1809 13th 1/2 St S Apt 4 INSURER C :

Fargo, ND 58103* INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

LOCATION OF PREMISES / DESCRIPTION OF PROPERTY (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
*address listed above

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFFECTIVE POLICY EXPIRATION
TYPE OF INSURANCE POLICY NUMBER COVERED PROPERTY LIMITS
LTR DATE (MM/DD/YYYY) DATE (MM/DD/YYYY)
PROPERTY BUILDING $
CAUSES OF LOSS DEDUCTIBLES PERSONAL PROPERTY $ 26900
BASIC BUILDING BUSINESS INCOME $
BROAD EXTRA EXPENSE $
CONTENTS
SPECIAL RENTAL VALUE $
F 34-BF-B514-7 04/14/2024 04/14/2025
EARTHQUAKE BLANKET BUILDING $
WIND BLANKET PERS PROP $
FLOOD BLANKET BLDG & PP $
Liability $ 100000
$
INLAND MARINE TYPE OF POLICY $
CAUSES OF LOSS $
NAMED PERILS POLICY NUMBER $

$
CRIME $
TYPE OF POLICY $

$
BOILER & MACHINERY / $
EQUIPMENT BREAKDOWN
$

$
SPECIAL CONDITIONS / OTHER COVERAGES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

Silverleaf Property Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 12367
Columbus OH 43212
AUTHORIZED REPRESENTATIVE
Completed by an authorized State Farm representative. If signature
is required, please contact agent.

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