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SOCIETY INSURANCE, a mutual company
THIS POLICY IS NON-ASSESSABLE
Business Description:
BUSINESSOWNERS POLICY DECLARATIONS
RENEWAL CERTIFICATE
Policy
No.
INCEPTION (Mo. Day Yr.)(12:01 AM Standard Time at your mailing address)
03 21 07
EXPIRATION (Mo. Day Yr.)
03/21/08
RENEWAL OR REWRITE OF NO.
BOP 449055
BOP449055
Insured's Name and Mailing Address
VINTAGE WINE CO
Alexmadison LLC DBA
1103 E WASHINGTON AVE
OSHKOSH W][ 54901
WINE SHOP
'X'IF SUPPLEMENTAL DECLARATION
C81 SUPPLEMENTAL DECLARATION
Form of Business:
Prems. No.
PROPERTY
I PREMS. NO. I BLDG. NO. I PREMS. NO. I BLDG. NO.
SEE ATTACHED SUPPLEMENTAL DECLARATIONS'
SEE ATTACHED SUPPLEMENTAL DECLARATIONS
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SEEA TT ACHED SUPPLEMENTAL DECLARATIONS
Deductible $ SEE ATTACHED SUPPLEMENTAL DECLARATIONS
OPTIONAL COVERAGES
Liability and Medical Expenses
Medical Expenses
Fire Legal Liability
$
$
$
1,000,000
5,000 per person
300,000 anyone fire or explosion
TERRORISM PREMIUM CHARGE $
TOTAL PREMIUM $
FORMS AND ENDORSEMENTS: . SEE ATTACHED SCHEDULE
o
620
PAYABLE: Quarterly
DIRECT BILL
COUNTERSIGNATURE DATE
AGENCY AT
AGENT AND NUMBER
]
01/29/07
MCCLONE AGENCY INC
00419
. ,
THESE DECLARA TIONS, TOGETHER WITH THE COVEAAGE FORM(S), COMMON POLICY CONDITIONS AND. FORMS
AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY.
THE ABOVE NUMBERED POLICY IS RENEWED FOR A PERIOD OF ONE YEAR. THIS CERTIFICATE IS SUBJECT TO ALL THE
TERMS, CONDITIONS, FORMS AND ENDORSEMENTS ATTACHED TO THEPOUCY ORTO THIS CERTIFICATE.
BP 2000 (0596)
Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1984, 1985
C20 52
01/29/07
Memorandum Copy
SOCIETY INSURANCE, a mutual company
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Form
BP0127
BP0417
BP0515
BP 500
SAI 41
TBP2
TBP 6
TBP 9
0106
0702
0103
0104
0902
0905
0904
0902
52