Oklahoma Farm Bureau Mutual Insurance Company DECLARATIONS PAGE

2501 N. Stiles Oklahoma City, Oklahoma 73105 Standard Fire Policy

Agent # & Name: 05802 - POOL INVESTMENTS LLC, DOD

County Office: Comanche County Farm Bureau
(580) 353-5173
Member Number: 09808799
Not a Statement of Premium Due

Policy Number: CFM00320525-01 Version: 2

Policyholder Name: Dwight Tanner

Policyholder Mailing Dwight Tanner

Name & Address: PO BOX 2851
Lawton, OK 73502-2851

This policy includes these Declarations pages and all Coverages and Endorsements identified on these Declarations pages.

Effective Date: 12/15/2023 Expiration Date: 12/15/2024 Amended Date: 01/11/2024 Type: Endorsement

Policy Period: 12:01 AM standard time as to each of said dates at the address shown; and such like terms thereafter as
the required premium is paid by the insured on or before expiration of the current term and is accepted by the company.

Amended Reason:
OFB8485 Roof Exclusion Endorsement Added on [Loc:1 Risk:1 Dwelling];

DEDUCTIBLE - See specific location for Deductible

Coverage Summary

PROPERTY COVERAGE SUMMARY LIMITS PREMIUM

Dwelling (See Schedule of Risks for limits) $920

LIABILITY COVERAGE
Coverage E - Liability (each occurrence) 500,000 $21
Coverage F - Medical Payments (each person) 5,000 $8

DISCOUNTS (See Schedule of Risks for limits)

Companion Discount APPLIED
TOTAL POLICY PREMIUM $949

Signed Date 01/15/2024

Other Coverages, Limits and Exclusions apply

Refer to your policy

CTF-0200 (4-2020) INSURED COPY Page 1

 Oklahoma Farm Bureau Mutual Insurance Company DECLARATIONS PAGE
2501 N. Stiles Oklahoma City, Oklahoma 73105 Standard Fire Policy

Agent # & Name: 05802 - POOL INVESTMENTS LLC, DOD

County Office: Comanche County Farm Bureau
(580) 353-5173
Policy Number: CFM00320525-01 Version: 2
Policyholder Name: Dwight Tanner

This policy includes these Declarations pages and all Coverages and Endorsements identified on these Declarations pages.

Effective Date: 12/15/2023 Expiration Date: 12/15/2024 Amended Date: 01/11/2024 Type: Endorsement

Policy Period: 12:01 AM standard time as to each of said dates at the address shown; and such like terms thereafter as
the required premium is paid by the insured on or before expiration of the current term and is accepted by the company.

ENDORSEMENT FORMS (Applies to risks shown)

CTF-Bk01 04/20: Standard Fire Policy - Dwelling Building and Contents - Basic
Form (Loc 1/Item 1)
CTF-Bk05 04/20: Liability Endorsement (Loc 1/Item 1)
OFB-8485 03-2012: Roof Exclusion Endorsement (Loc 1/Item 1)
Policy Locations and Risks
Loc # 001 Street Address All Risks Under This Location Subject to Deductible of: $2,000
170501 N 2740 Rd , Duncan, OK 73533-2741

Loc/Risk 001/001 DWELLING Form Basic with VMM Deductible: See Location Deductible
Section I Limits Premium
Dwelling - Fire, Lightning and Extended Coverage 135,000 $844
Vandalism $20
Personal Property - Fire, Lightning and Extended Coverage 10,000 $55
Vandalism $1
Roof Exclusion Endorsement Applied

Discounts
Companion Discount Applied
Total Premium $920

CTF-0200 (4-2020) INSURED COPY Page 2

 Oklahoma Farm Bureau Mutual Insurance Company
Policy Period: 12/15/2023 To: 12/15/2024
Attachment To: Policy Number: CFM00320525-01 Amended Declaration Date: 12/15/2023
Applicant Name: Dwight Tanner

Standard Fire Policy

Roof Exclusion Endorsement

The policy is amended as follows:

This endorsement applies to all coverages.

We do not cover windstorm or hail loss to the roof surfacing of the dwelling covered by this policy. We
do not cover loss to the interior of the dwelling covered by this policy, or personal property within the
dwelling, caused by rain, snow, sand, sleet or dust, if the loss resulted from the condition of the roof
surfacing.

This endorsement applies to the locations shown below.

Location/Risk
170501 N 2740 Rd , Duncan, OK 73533-2741 Item 1 1980 BrickStoneMasonry

Signature on File Date on File

Signature of Insured Date

OFB-8485 (3-2012) 1
Page
04/19/2012