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Page No
<br />Policy Number
<br />By
<br />BOOK
<br />-9
<br />i'o`e? 3
<br />0
<br />STATEMENT
<br />OF
<br />VALUES
<br />(FOR USE WITH INSTITUTIONAL PROGRAM)
<br />Name of Company
<br />Fc.^r.::iL:.%
<br />I
<br />DESCRIPTION AND LOCATION
<br />V A L U E S
<br />This S
<br />e lo: P
<br />ti
<br />;un
<br />No.
<br />OF PROPERTY
<br />A-Building B Puseml Propery
<br />t
<br />Actual Cash Value
<br />Coal
<br />Replacement
<br />When Appbeable
<br />pac
<br />.a
<br />nr
<br />O".u1.a6.u Use
<br />20.
<br />a. 1072 Guerdon Piobi'• e3ome
<br />Ser. No. 541
<br />Old Pumping Station
<br />1,500.
<br />b. Personal ProDerty
<br />NIL
<br />30.
<br />a. r_ault Education Center
<br />(School Bated 401 mash)
<br />1500 Nas'. Street
<br />E-4,200.
<br />b. Personal Frcperts
<br />T
<br />NIL
<br />31.
<br />a. Bangers Quarters (Dwelling)
<br />San Lee Par}_
<br />35,000.
<br />b. Personal Fropert;y
<br />NIL
<br />32. (
<br />a. D"Oadway (Lee ;Co.)l Co=-init
<br />U
<br />lzldg. (35113 Cape Tear Rura
<br />l
<br />Fire Dist) 401 I:. Eain,
<br />Broadway
<br />5E,000.
<br />b. ersonal Property
<br />IIL
<br />33. I
<br />a. Comfort Station
<br />I
<br />San Lee Recreation Far!:
<br />.i/S 53:-1/2 mile
<br />3ast of Sanford
<br />b. = ersonal ProDert..
<br />1,T1,
<br />INSTRUCTIONS:
<br />1. The values shown should reflect the basis of coverage (AC\' o. Replacement Cost) for each item and for either Cote-.ace A
<br />- Buildings, Coverage B - Personal Propertv or both.
<br />2. Include in building values
<br />a. building service and maintenance equipment owned by the insured,
<br />b. floor covering-- fastened to floors o. walls, fixed seat and desks, fixed tabies, railings. altars, clocks. bells. fire curaius,
<br />and stained glass windows,
<br />e. all permanent fixtures (including organ(s)) being a permanent part of the building.
<br />d. mirrors, air conditioners, domestic appliances, fire extinguishing equipment, outdoor equipment.
<br />3. Include in personal property values, personal property, including the legal liability of the insured for similar property I.ciong.
<br />ing in whole or in part to others and held by the insured, in each building which is not otherwise a part of building values.
<br />4. The following are not covered and their value should not be included in value shown:
<br />a. brick, stone or concrete foundations which are below the undersurfacc of the lowest basement floor, or where there is ne
<br />basement, which are below the surface of the ground inside the foundation wall- of the building,
<br />b. foundations of machinery or boilers and engines which are below the surface of the ground,
<br />e. pilings, piers, pipes, flues, wiring and drains which are underground,
<br />d. those portions of walks, roadways and other payed surfaces which are outside of building
<br />e. land values, cost of excavations, grading or filing.
<br />I. ]awns, trees, shrubs, plants, growing crop=s,
<br />g. motor boats, sail boats, aircraft, automobiles and self-propelled vehicie< or machines except motorized equipment nc.
<br />licensed for us on public thoroug'nfares and operated principally on the premises,
<br />h. animals and pets,
<br />i. household furniture in apar=ents occupied by the insured. any officer, director, stockholder or par trier of the ins::red or any
<br />relative of the foregoing.
<br />5. Nothing contained in these instructions shall be construed as changing in any manner the conditions of the policy.
<br />F..-m MLE-24 (Ed. 5-69) (OVER) Page 1 G!
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