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Insurance Policy - 15555 Millard Ave, Markham, IL 60428.pdf

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Wed Nov 17 15:29:08 CST 2021 Shelter Mutual Insurance Company 1817 W Broadway Columbia, MO 65218 1-800-SHELTER (743-5837) Dwelling Insurance Policy Evidence Of Insurance As Of 11/17/2021 Policy Number: Effective Date: Expiration Date: Named Insured: LOFTY HOLDING 15555 MILLARD AVENUE LLC 11718 FOLKSTONE LN LOS ANGELES, CA 90077-1310 Agent: 12-73-10784513-38 11/17/2021 (3:16 PM CST) 11/17/2022 (12:01 AM CST) LUKE ROTH 34-AB19-85 2245 W DUBLIN GRANVILLE RD WORTHINGTON, OH 43085-3336 (614) 832-7949

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Wed Nov 17 15:29:08 CST 2021
Shelter Mutual Insurance Company
1817 W Broadway
Columbia, MO 65218
1-800-SHELTER (743-5837)

Dwelling Insurance Policy
Evidence Of Insurance
As Of 11/17/2021
Policy Number:
Effective Date:
Expiration Date:

Named Insured:
LOFTY HOLDING 15555 MILLARD
AVENUE LLC
11718 FOLKSTONE LN
LOS ANGELES, CA 90077-1310

Agent:

12-73-10784513-38
11/17/2021 (3:16 PM CST)
11/17/2022 (12:01 AM CST)
LUKE ROTH
34-AB19-85
2245 W DUBLIN GRANVILLE RD
WORTHINGTON, OH 43085-3336
(614) 832-7949

Policy Deductible
$1,000
Described Premises
15555 MILLARD AVE MARKHAM, IL 60428

Description
FRAME, NON-OWNER, 1 FAMILY DWELLING, W/
MINE SUBSIDENCE

Coverages

Limits

Dwelling
Frame, W/ Mine Subsidence
Addition of the Peril of Vandalism
Mine Subsidence Coverage Endorsement
Loss of Rents
Additional Living Expense
Drainage System Endorsement

Endorsement
Number

$137,500
$10,000

$621.00
$42.00
B-847.2-B
B-313.17-B

$13,750
$13,750
$10,000

B-102.7-B

Total for Term (This is Not a Bill):
Policy forms and additional endorsements attached to this policy
Loss of Rents
Additional Living Expense
Landlords Liability Coverage and Medical Payments Coverage
1000
Policy Term: 12 months
Zone Code: 001

Premium

$854.00

Number
RENTLOSS
ADDEXP
B-454.15-B

Protection Class: 5

Secretary

President and CEO
End of Evidence Of Insurance

B-750.1-B

Page 1 of 1

Wed Nov 17 15:29:08 CST 2021

SHELTER INSURANCE COMPANIES
1817 WEST BROADWAY, COLUMBIA, MISSOURI 65218-0001
ShelterInsurance.com
Phone:1-800-SHELTER
Federal Tax ID: 43-0613000
Cardholder

Payment Amount

LOFTY HOLDING 15555 MILLARD AVENUE LLC

854.00

Card Number

Transaction Number

Agent Number

Date Payment Received

************1165

1859

34-AB19-85

11/17/2021

Authorization Code
13AFBC

Transaction Payment Type
MasterCard

Credit

Transaction Type

Card Transaction ID Number

Purchase

15398489

Risk Description

Payment Amount

Payment Detail
Policy Number
12-73-10784513-38

Insured Name
NB

LOFTY HOLDING 15555 MILLARD AVENUE
LLC

15555 MILLARD AVE

Total Payment Received:
For policy details or payment questions, please contact your agent or call 1-800-SHELTER (1-800-743-5837).

M-1408.2-M

Receipt

854.00

854.00