Name      

Address   

City 

State  ND MN

Phone #     

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Policy # 32-- 01 07 08 11 12 13 14 16 22 ---

Please complete below:

Change Deductible to: 500/1000 wind hail 1000 500/2500 wind hail

 Year of  Roofing to  

Value of Home to  

Delete Coverage on

           on Policy #     

Delete All Coverage on Policy #

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