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STATE FARM FIRE AND CASUALTY COMPANY <br /> A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON,ILLINOIS DECLARATIONS <br /> Fq goxdson,8539 75085-3925 Policy Number 98-C9-R412-4 <br /> Ric ar <br /> Named Insured Policy Period Effective Date Expiration Date <br /> M-15-2783-FC14 F N 12 Months NOV 3 2020 NOV 3 2021 <br /> 001437 3123 The poli y period begins and ends at 12:01 am standard <br /> BUTTERS, ROBERT lime at the premises location. <br /> 1909 HEWITT AVE APT 4 <br /> EVERETT WA 98201-3177 Agent and MailingAddress <br /> 9 <br /> JEFFREY TAYLOR <br /> 4850 RAINIER AVE S <br /> SEATTLE WA 98118-1742 <br /> IIIIIIIIIIII111111111111IIuIIIII'll..IllIIl 1111IlllIllIlu1lil11 <br /> PHONE: (206) 725-8008 <br /> a <br /> Businessowners Policy <br /> Automatic Renewal-If the policy period is shown as 12 months,this policy will be renewed automatically subject to the premiums,rules and <br /> forms in effect for each succeeding policy period.If this policy is terminated,we will give you and the Mortgagee/Lienholder written notice in <br /> compliance with the policy provisions or as required by law. <br /> Entity: Individual <br /> POLICY PREMIUM $ 481.00 <br /> Prepared <br /> NOV 10 2020 ®Copyright,State Farm Mutual Automobile Insurance Company,2008 <br /> CMP-4000 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. <br /> 010960 290 I Continued on Reverse Side of Page Page 1 of 6 <br /> N 1R <br /> 530-656 a.2 05-31-2011(o113231c) <br />