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Nov 17 09 01:25p LPFD 2098872821 <br /> • p.2 <br /> NAUTILUS INSURANCE COMPANY <br /> COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> POLICY NUMBER: NC951010 <br /> ® Extension of Declarations is attached. Effective Date, 11/01/2009 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) $ 2,00C,000 <br /> Products/Completed Operations Aggregate Limit $ INCLUDED <br /> Personai and Advertising Injury Limit $—1,000,000 Any One Person Or Organization <br /> Each Occurrence Limit $ 1,040,000 <br /> Damage To Premises Rented To You Limit S— 100,000 Any One Premises <br /> Medical Expense Limit $ 5,000 Any One Person f <br /> r 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 ORGAIZA=ION <br /> LOCATION OF ALL PREMISES YOU OWN,RENT,OR OCCUPY: ❑ Location address is same as mailing address. <br /> 1. VARIOUS <br /> LINDEN CA - l <br /> 2. <br /> Additional locations(if any)will be shown on form S170. <br /> LOCATION OF JOB SITE (1f Designated Projects are to be Scheduled): <br /> PREMIUM RATE ADVANCE <br /> CODE#- CLASSIFICATION BASIS PRICO All Other PREMIUM <br /> 4167C - Clubs-civic, service or social-no buildings T 161 INCLUDED INCLUDED <br /> or premises owned or leased except for 2.959 478 <br /> office purposes-NFP <br /> Rate is Each Member <br /> i <br /> i <br /> 9o556 - Special Events-Group I-Up to 500 T 1 INCLUDED INCLUDED <br /> average dai!y attendance 75.55 7 7 6 <br /> Rate is Attendance Per Day <br /> CHRISTMAS TREE LIGHTING 1215109 <br /> I <br /> 90556 - Special Events-Group I-Up to 500 T 1 INCLUDED INCLUDED <br /> average daily attendance <br /> Rate is Attendance Per Day ` 75.570 76 <br /> CHERRY FESITVAL 5115110 <br /> 90557 - Special Events-Group 1-501-1,500 _ 1 INCLUDED I INCLUDED <br /> average daily attendance <br /> Rate is Attendance Per Day 120.250 120 ` <br /> JR MISS COMPETITION 3!6!10 <br /> * PREMIUM BASIS SYMBOLS =Products/Completed Operations are subject to the General Aggregate Limit <br /> a =Area (per 1,000 sq.ft.of areal 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 PAGE $ 750 <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 /> S'SQ (11 W04) Includes copyrighted material of Insurance Services Office,dne.with its permission,. <br /> ) Copyright ISO Properties,inc.,2000 <br />