HomeMy WebLinkAbout000150.tiff UNIFORM STANDARD FORM NO. t2
BINDER (Edition Aug. '59)
Pacific National _-..__ .. _Insurance Company of
Pending the issuance of Policy, and in consideration of the stipulations herein contained. this Company is hereby bound to
Weld County
and legal representatives, for thi.rty ___- ... .......-_slays, to sit: from Noon (Stmesa rd 'Pine) of
•
MOy1, 19 43 until Noon (Standard Time) of June 1, 19.. .63-, at loo neon of prop-
erty involved, against directl R
ns, by . fire, extended coverage & van1#sm &'malicious mischief'
to an amount tot exceeding See Statement of values attached di Ibis. to the
following described property while located and contained as descrihrd herein. ;rid not elsewhere, to fait:
Rate
on As per Statement of Values attached
PIP Policy
On
On .. _. .
and situated.. - -- _--
City or Town of Weld County .State of Colorado-_. _..._.. _ . .
State Clauses applying._
It is expressly stipulated that this bind •r is issued subject to all the terms and conditions of the policy rev t .trly issued
by the Company in this State, which policy is hereby made a part hereof to the same extent as if fully sit forth h rd in: to
the payment of such premium as near be found to be due to this Company,whist premium, in the event of loss before expiration
of this binder, shall he fixed at the Cull annual premium for the suns insured.
It is a condition of this binder that whenever the Policy of this Company is issued in lien of its under! tlsico under this
hinder, its obligation hereunder shall cease and be void: provided, however, that this hinder shall not nnttinue in oi-c hi-soto
the expiration :late stated herein.
In no event shall this hinder continue in force beyond fifteen(15) days from the effective date of this hinder.
This binder is made and site red subject to the bregoing stipulations and conditions and Man not b• vbid Inds duet
tersigned by the duly authorized agent of this Coutp:uts.
�.-ter
Dated at
Creel Colorado, ,his _._1st day of _. _.. .1'163....
_. -
3 _O ; _-Is
Reason for Binder_.a copy of this binder being forwarded to the Bureau?. no (direct to H.0.)
YEAR MO. DAY
tiNli0 Miry Form No. 12 (8.59) Date of Cancellation, - -Date of Binder,
Time in Force,
IMPORTANT NOTE TO AGENTS.
Annual Premium, $ --------All binders to be issued in quadruplicate—the original for Premium Earned,the Insured, one copy to be forwarded directly to the Company, Short Rate or Pro Rata
one copy to the Bureau and one eery for the Agent's files. If Cancelled Pro Rata Or Flat, Explain Why
If this binder is cancelled or terminated without theissuance of a policy, the original binder or copy thereof must be -
submitted to the Bureau and earned premium charged subject to
the rules governing "Short Rates and Cancellations" and
"Binders" published by the Bureau. (Sign Here)
150 .C.ENT
fAUTRENTIC11 ' S'r ATE MI',NT OF VALUES PI. Fnun vl,. I.
R:d,Ii,nl adnt,h I OWI
(FOR USE ONLY WITH RATING PLAN FOR COTTHIN'. PUNT.IC PIIOI'IEIYIT
l OR EDUCATIONAL INSILTUTIONS. C IIUNCHI.E AND II'SPIT AI_SI
Page No
ALL VALUES SHOWN ARE
.,gACTUAL CASH VALUE I I REPLACEMENT COST.
INSURED Wald 00Ullr
MAIN OFFICE ADDRESS a, Colorado
V A I II I S I'NOP(IIIY
DIEM DESCRIPTION AND IGCAIION IN WE 'Hb'APAci fOR HATING
NO OF PROPERTY HMI DING OR',IRO( IWO I CONTINIS Oil N OT ANL/1110N IR,1
arikklit
1.
2. Court Hours $1,100,000. 1120 000.
t0ouny Jail 151,200. 5,000.,
5. Welfare Chios 55,000. 8,500`
7 a ,
Op a Po Basso 3,500. 137,0`00.
��"
w ft!i
8. 7
9. County 0 12000. 28,000.
10. Natal Sty
000. 16,000.
U. � 5
Warehouse 1.11775. k/8
l 5
50.
13. 011 solar 12,000. 2,000.
ISLAND 01011 Pa
11. Lb a orraoo 68,500. NIL
15. Stores* 11dg. 1,000. H11.
16. Drit... Lissome kraut 9 500. 6,800.
l7. animal Ptedrotion ,200 NIL
opr 18. ' Atol lab. 16.600.19 Poultry soaAnp $141. 7,200. 1.000.
20 i Aetbit Ads"4t 114j. 1,600. 1100.
21. , 1n xia4. m s3, 6,000.
U. iii Hair p
U. LI.na$ook Adds It ;B1AA, , 68.000. 1.000.
211. l i dlag Moot abed (Mo. sand 6100. MI.
25. Hera Shod (No. Comm sbadd 5600. NII.
26. :and 1348. 3,100. 1.600.
27. I Mi. tea• 2,500. 1.000.
1,5IIlI', IPI.NF To I r Ind, in I nadir,, `rilt. IIlI at. i, 1Ii.i,i. , I , ,ulln I Varm.,.,. , .tut{, l ,l.ii.. II. ,, .
In i,Idmr I In,l ,,i'..
.ill., %1. Ind
al ._ t Il lar,Id, ,I � I I ,In,. 'I K ll rr6e L.
„e„
.ITD. 'rl',,,, ,ri, cal..., ,,, to n.n n ..1 Lu:Idn, .J ,J. I- !H...',,,.,. ..u, d Ln.I,I : , r,u„ ....d ,..I i,,,. . ,. it: ,,,
Oil,
In ,L. 1 .,red L:,. ,,,, G.,bil , ,d, unl, . ..I< .. ., ,.... I, ill, .:,lu,. ,L, , L.I.. .,...,1 ,..,,_ 1.,
„Ina. . . I . ,�. ,� ,,. ,I ill or I d, op.tr 1 lurl. Dint t 11.. Pal I.. rl.,lrrow,... II.1., N. T I ,p . . trio.
.I. Ion,. d , r, .....I d. I,-,e „ ,.I„ , „ .n„I • o- .,o r in, rr r . l
V Ir. The tullcrwing rot l 11,11,' 1 II v;Im ,F ul I .h Ind
(D, Inn k. .u.na !Jr ,seer to I u fat o a dic ud nyy fou 1 [ n. yt in ii I I.IrL , ,I „I . M1„
la.•tu 11 All..“ the, , . 1. NIn,l, t).I..., II.. IiII, Ii I I, Ile , ,II- I, , I ...L...
^Po IInt., v i,g and Orrin. xh d . ,InH II„ lu„n., n.JD.., Ia ud 1,- F''''' I u ,'. 'In, .
Nil] , thall ]5 tr,', Lr. , , Il, Lu I Nnr, fi J Ian hl,�.. c -t ui uy, Uhl'', ....
1.0.0.1, .ul } afi a,tom,Lilva and frill id d II,.I ,yh.,,I .r hire ,x III m, to d yugI , ,I I ,� _ ,. ,iIII .
I1 ,�L.. glLu.. .a.l I a Iv Clall, on the 00 misc..
Any modification in these in structlona shall be In accordance with the rules of and satisfactory to the Rating Organization when. the ',tab Trent of
values" Is to he filed.
•
qq-A--blaEarlc STATEMENT OF VALUES P.I. Form No. 6
IL'•• Edition March 1960
(FOR USE ONLY WITH RATING PLAN FOR COVERING PUBLIC PROPERTY
OR EDUCATIONAL INSTITUTIONS, CHURCHES AND HOSPITALS)
Page No
ALL VALUES SHOWN ARE L*ACTUAL CASH VALIJE L , REPLACEMENT COST.
INSURED Mold County
MAIN OFFICE ADDRESS
ITEM DESCRIPTION AND LOCATION V A I. U E S PROPERTY THIS SPACE FOR RATING
IN THE
NO. OF PROPECTY BUIE DING OR STRUCTURE CONTENTS OPEN ORS/NIZATION USE
80. ON,.. - Qr.Twr,IColo. 4000. 4000.
�. AsYlla� - arannr 2,500. JELL
30. Sar°11r.31. 750.2,900. 000.
P. 1 Oar Oers TOO.
E .... Shed Ilieldimi Shed 1 2, 00.
00.
. & Rapids ZIdg. 7,200. ! ,
3'. Oases 9,500. lip
37. 2,600,
3'. bele ].200. 148°II°::
ge. GOV41$11 3,300. 800
DM1111eg 3,000. NIL
11.. 1M 2,300. NIL
11t. aiiiillias j,000. NIL
III3. ratan 3,100. 8
16. 00611.1ai Wu are 6 e850. 850. 00
S. MPS 4800. 800.
S.
hi. Aw13$ 3,300. 800.
I ,m'
DISTNICT #2 . WINneq
9. Oinge 6,850. 80.
IN$"I'NI't"T MINN--PO I rhl.lr in lull Ili v.JG . o Ion,L., Is,., mouldy,i L nd „IItI•nu iii
building al.. doc(hrd .ign . el.dl., _I I. i.l ,Idl II��I P, Nino, a L.,.. ,n' IF u.. IL.
I
l., n.
IIJ ?r' 'I ,earn,ul. owl III III Willi ." ..III .,I. Hill loo ml ,w I. I,—ie i.r. I, Orr.. ,.IIL-. V a u ' „6. ..i i., PI ,, I,.
..tilatrl Idle
•
IL Ioh of h `tA ulr n :.LI l . l.. ell L,II „b�, l !L EL oh: .. to
whioh OA h , rl ha . u of Ii.J I. "I� a l Phriwls "1(I( ill( 1 lila kii i a- III u Mr.,-I li l l. ii LI i, AL.llr IA l it ` „li„I
o in when
hi in
II 'I'II IL, III II lilt Lida I . uI1. '�LI P. I. 'l1iI Giulio, I,I II. �I.i.:III ,
.hl i ,,. .IIL ,nl I II, I,. ,, I, hl n ,, I. ,I - III III LL, In 11 „
.I rw�,l i I. A i�
_11 , I'
Noi,- 'ill. OLIO.,luo 'IL mn nnrlr d au:I Ili,, ,,IIA, Jwu)II ul.l 1,.• nn IwL.:I i,i Ju 14.L.
III I,II,I. ohne .ir chht r,iC tutu.ILHu elwill, foundation. , II, L. i.- . A I.i,1, L I., , Ili C L o i , ,
1 , i. II w I, I, I N1 l [1111111, I :L I L. II.,
P . IPPI .III.. 1 6 nI.laII tl III .I II I III, i . hill „
n•l
Irbil. II. II. d . ill Ile .pip,.._
Any mudlficallon In These Insl mrtlons nil II Dr LA a,Imdan., with the ruler. of and sal lstarlo I) To the Dahlia II,K.Inl,nllan whr, IN. "nl.Ilouu M nl
value+" is To De tiled,
4.
HAUTNENTICry STATEMENT
Page
OF VALUES
(FOR USE ONLY WITH RATING PLAN FOR COVERING PUBLIC PROPER V 1_ Form No, og No.. OR EDUCATIONAL INSTITUTIONS, CITTIRcIIFS AND IIo5PI I Abs( b' Lliuu March 1950
ALL VALUES SHOWN ARE f *ACTUAL CASH VALUE i ' REPLACEMENT COST.
INSURED. _ • 00fan4
MAIN OFFICE ADDRESS
ITEM DESCRIPTION AND LOCATION
NO
OF PROPERTY VALDES ---�_
— PROPINIY
BAIT DING OR SIRED:MR1 T INTEND, I IN Till Ib l[tiPACI ION NAfING
DPI HCANIIAIION IIti!
EVINt
SO. Ames
51. i1 Moon 8
200,
St. x
53. hrl BoaN 2,35 80
1n5 40
208 Sr. b ilookta• Sled �Mk
• b,
• as .2 e,�Os Wen*
259. Dallipg
60. Pool Baum
�aMegt
,5 1'
e1. Tool Maus 175 32 66t. so ms.
15 22
oanp 7,2ao 4,
S. Of o ae,D5
O. 0� 2,2
Cl 3,2
60• Oj
382It 88
0. afil'opil
1.57
Tor I l
I N,v ,'„UNS- MILL) CO. T
I, !alumJoachim'
iii 11 r l wPI
ill ,\Iu -Improvement,
it rattemkt,. hell 'I valor..
Iori et. I , i Hue, lulu _
Gt Show
.nl H II, rrri nA JI tins r hr II Lmll r: L,rr t ir.� I e ii,. I
I rl I L
r-I i. Icr I. I y II r .I. 'I A II i�. I ill.
I Ih I I . ^t II I I,rri lIl rl' � � rr
a .J t nil
lib I I-rl 'n "WI.
I qr,a Pc i;,.11.,
I illy,
I I :I bnJ I I I i, r
hty in machine,il ni Include arid ..Hr. II A P I ., [To l a I . roll .„i T •..I li .r lied..
tirt � 1 ,,��r. l l ... ,l . Il l .I,u nlu I ,, i'
Note: The I II .rill 1 1 l n t l li�r. Lrin.r-r
u 1 _I -t-I m ro'.
basement eb ct n concrete foundations. Ncinitnu f u datio . t Ili.halm. ilia, .I n.ra r
pipes. IIthere m . i 1 which I T,w the I nip.I wiring I f On. r I "I.w 11 t
and u rLji II r I A ! n I L:. n.r l r t I I I 1, u l 1 Lu�. oll II � I. ul I AP Ir ix
I:' im t ,r I I -t - - t t d O ,"I hr,l r 1 ubrn inn ughf o.ie er I e r I aII.noriml I .II II I r ins I wading ai _I II ` t l'i n . to
Any values" is beIen thee¢ Ina[ructlons ¢hall be In eccorGence with th r '�e'It m u rr
la to modification Bled.
riz e ,I eo. e.
e rules of and satisfactory to the Rating Organization where the "s[e.temenr of
AUTHENTO STATEMENT OF VALUES Y.I. Form No. 6
tgq1� II Edition March 1060
(FOR USE ONLY A RATING PLAN FORCHURCHES
COVERING PUH OS PROPER 1'Y
OR EDUCATIONAL INSTITUTIONS, GHV RCHF.S AND HOSPITALS;
Page No _..b
ALL VALUES SHOWN ARE S, ACTUAL CASH VALUE H REPLACEMENT COST.
INSURED Wald Cam1tr
MAIN OFFICE ADDRESS
vaI II rwaiNTr
ITEM OESCRIPTIOrl AND IOCA'ION THE HIS SPA( I FOR RATING
NO. Of PROP,PIO HAIL PING OR SIR JCI HIRE P.ONIHi15 '"IN CNCANIIMION IISI'
I �
72. Qesp 850. loo.
73. HUW(1I
73. aa�'i� 2,850, 200.
711. 2,350. 200.
T5. ar'�g"ox 2.700. 2000. 1,
76. Galt 2,600. 300.
Ii I
•
INS'fkIII' UN5:—lal Intloleto Inn Hots .Jae. atchi e , :mli r ald it and it Hill' � I.:, nu. 0th
Ipuildilik4 a is attached h Ilan I ul I
III Show lnd ,n. to o I II tll Tut.," Liu,. I.1, I' 11lhna- t r.in d. d i.nat n., il.. I.L . "I IS II ' Isla r , all .n in a,
\t'1 t. '
1 1 Int loft t t 1s", sato, ll too,At , tuition,: el I tl C mii il: ,II I I I' l IE
P
.}Hell that rel ha .ro wul II Tiro 1, l tilt .aim lit ul la an-I H. pi I I .:r.. I. ,.I:Je
P.,it to others
It Ply]. ty thr dproIncI e li dac lAl, Lo sowed to I hid,lit occi'el, tot n t 31111 r - . I. t
air Lch and ,qullwa I th ,. o I o.l 1111, I • r m,l,l �t _�t 1 ..I� rl .te l TIN
'Stat enn ci
N t Ile fn111 wnig a r. nut a r I dtol tht hut .I I the b: Indol , shL:
lit look, stone or concrete Inumletion. inoitlion,i foundation. 1 I • 1 I t I II- I l c I I
•
I est.int nt nun -In thewI .ph(TIT, ‘011111 an II.I. v I tlir
111I f1 \O HO, den 1; II c',11,1 II 11k. I Iel.ler II 1 Ju
, I that . feet distant o b Id I I: I.I 1 ill.. t I, 11 I 1 ,
. m .111 �i r i .
(lit,. p, moth]r beta rnl I 3 .. �er.Jt � ro:h�lr. I -olI pi^P.II. . it'a& . eae I• bnl I 4., u nn- a n li., �,
tmh Ge tLu rnuglit:u's 31,11 «to rate l PI In,3p;Jh ..I the pun!, ,
Any modification in these inatrucl ions shall he in accordance with the rules of and satisfactory to the Rating 0ryani,atlas whet the "statement of
values" Is to be filed.
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