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State Farm Insurance <br />PO Box 2915 <br />Bloomington, IL 61702-2915 <br />DAY, PHILIP <br />1039 WILSON AVE <br />SAINT PAUL MN 55106-5630 <br />Renewal Declarations <br />State Farm <br />State Farm Fire and Casualty Company <br />A stock company with home offices in Bloomington, Illinois <br />Your State Farm Agent <br />Sarah DeBruin <br />758 Stillwater Rd <br />Saint Paul MN 55115 <br />Bus: 651-636-6777 <br />Email: sarah.debruin.ts5r@statefarm.com <br />Policy number: 93-EF-Z306-6 Effective date: June 3, 2023 <br />Policy period: 12 months Expiration date: June 3, 2024 <br />The policy period begins and ends at 12:01 am standard time at the premises location. <br />RESTAURANT POLICY <br />Automatic renewal - If the State Farm° policy period is shown as 12 months, this policy will be renewed automatically subject to the <br />premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the <br />Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law. <br />NAMED INSURED <br />DAY, PHILIP <br />ENTITY <br />Sole Proprietorship -Individual <br />IMPORTANT MESSAGE(S) <br />Notice - Information concerning changes in your policy language is included. Please call your agent if you have any questions. <br />To obtain a copy of your policy, please contact your State Farm Agent. <br />POLICY PREMIUM <br />This is not a bill. If an amount is due, then a separate statement will be sent prior to the due date. The premium(s) shown below is the 12 months <br />premium(s) for the characteristics of the policy as described in this Declarations. <br />Premium: $958.00 <br />Minnesota Fire Safety Surcharge: $1.79 <br />Minnesota Firefighters Relief Surcharge: $3.93 <br />Total Premium: $963.72 <br />Discounts applied: <br />Business Experience Rating <br />Years in Business <br />Renewal Discount <br />Business in Residence Premises <br />Policy number: 93-EF-Z306-6 <br />Prepared: March 27, 2023 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 <br />CMP Dec MN.1 <br />CMP-4000 <br />Page 1 of 5 <br />1009178 2011 152395 211 06-21-2021 <br />