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NAUTILUS INSURANCE COMPANY <br /> COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> POLICY NUMBER: NC591918 <br /> ❑ Extension of Declarations is attached. Effective Date: 11/01/2006 12:01 A.M. Standard Time <br /> LIMITS OF INSURANCE ❑ If box is checked, refer to form S132 for Limits of Insurance. <br /> General Aggregate Limit (Other Than Products/Completed Operations) $ 2, 000, 000 <br /> Products/Completed Operations Aggregate Limit $ INCLUDED <br /> Personal and Advertising Injury Limit $ 1, 000, 000 Any One Person Or Organization <br /> Each Occurrence Limit $ 1, 000, coo <br /> Damage To Premises Rented To You Limit $ 100, 000 Any One Premises <br /> Medical Expense Limit $ 5, 000 Any One Person <br /> RETROACTIVE DATE (CG 00 02 ONLY) <br /> This insurance does not apply to"bodily injury", "property damage"or"personal and advertising injury"which occurs <br /> before the Retroactive Date, if any, shown here: (Enter Date or"NONE'if no Retroactive Date applies) <br /> BUSINESS DESCRIPTION AND LOCATION OF PREMISES <br /> BUSINESS DESCRIPTION: NON PROFIT ORGANIZATION <br /> LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCCUPY: ❑ Location address Is same as mailing address. <br /> 1. 18S27 E. MAIN ST <br /> LINDEN CA 95236- <br /> 2. <br /> Additional locations (if any)will be shown on form S170. <br /> LOCATION OF JOB SITE (If Designated Projects are to be Scheduled): <br /> PREMIUM RATE ADVANCE <br /> CODE# - CLASSIFICATION * BASIS PR/CO All Other PREMIUM <br /> 41670 - Clubs-civic, service or social-no buildings t 130 INCLUDED INCLUDED <br /> or premises owned or leased except for 3 . 008 j 750 MP <br /> office purposes- NFP j <br /> Rate is Each Member <br /> l <br /> 90556 - Special Events-Group I -Up to 500 t 2 INCLUDED INCLUDED <br /> average daily attendance 71. 000 <br /> Rate is Attendance Per Day <br /> 90557 - Special Events-Group I -501-1,500 t 1 INCLUDED INCLUDED <br /> average daily attendance 113 .000 <br /> Rate is Attendance Per Day <br /> - ADDITIONAL INSURED 50 <br /> PER FORM CG2011 @$25.00 EACH <br /> i <br /> * PREMIUM BASIS SYMBOLS + = Products/Completed Operations are subject to the General Aggregate Limit <br /> a = Area (per 1,000 sq.ft.of area) o = Total Operating Expenses s = Gross Sales (per$1,000 of Gross Sales) <br /> c = Total Cost (per$1,000 of Total Cost) (per$1,000 Total Operating Expenditures) t = See Classification <br /> m = Admissions (per 1,000 Admissions) p = Payroll (per$1,000 of Payroll) u = Units (per unit) <br /> PREMIUM FOR THIS COVERAGE PART S 800 MP <br /> FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the policy) <br /> Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue: <br /> Refer to S902 Schedule of Forms and Endorsements <br /> THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. <br /> Includes copyrighted material of Insurance Services Office,Inc.with its permission. <br /> 3150 (10/04) Copyright ISO Properties,Inc.,2000 <br />