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Lindstrom Cleaning & Construction, Inc <br /> 9621 10th Avenue North <br /> Plymouth,Mn.p5441-5098 <br /> 763-544-8761 I <br /> Fed TIN 41-0847540 <br /> REPLACEMENT COST EXP ANATION OF PAYMENT <br /> Statement as to the full cost of r pair or replacement under the replacement cost coverage,subject to the terms and conditions <br /> of this policy. <br /> Claim Number:PP0016904928 <br /> Policy Number: 55RBD210391 <br /> Agent:CUSTOMER SERVICE <br /> Insured:JUDY&GEORGE D. UNK ROGOSHESKE <br /> Location:540 Old Crystal Bay Rel South,Long Lake,MN,55356 <br /> Type of propertyinvolved in clad :Building <br /> Date of Loss: 7/9/2016 <br /> 1.Full Amount of Insurance ap licable to the property for which claim is presented was $710,000.00 <br /> 2.Full Replacement Cost of the said property at the time of the loss was UNDETERMINED <br /> 3.The Full Cost of the Repair qr Replacement of the damaged property is.:$33,106.07 <br /> 4.Applicable Recoverable Depreiation is $13,179.60 <br /> 5.Applicable Non-recoverable D preciation is •$0.00 <br /> 6.Actual Cash Value loss is f • $19,926.47 <br /> 7.Less deductibles and/or participation by the insured • $1,000.00 <br /> 8.Actual Cash Value Claim is.t •$18,926.47 <br /> (Line 6 minus Line 7) <br /> 9.Supplemental Claim,to be fil d in accordance with the terms and Conditions of the Replacement Cost Coverage provided <br /> you notify us of your intent to do so within 180 days after the date of loss,will not exceed$13,179.60 <br /> (This figure is that portion of the mounts shown on Line 4 and 7, which is recoverable) <br /> Insured Signature Date Insured Signature Date • <br /> Sincerely, <br /> Erik Powers <br /> A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. <br /> Please be advised that nothing cotained within this document or any act of this company or its representatives is to be construed <br /> as a waiver of any known or unknown defense we may have under the policy.Nor does this letter waive or change any <br /> provisions or conditions of the po icy. <br /> JUDY_&_GEORGE_REVISE 8/11/2016 Page:4 <br />