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COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> POLICY NUMBER: NN393078 <br /> ® Extension of Declarations is attached. Effective Date: 11/01/2013 12:01 A.M.Standard Time <br /> LIMITS OF INSURANCE ❑ If box is checked, refer to form S132Amendment of 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, 000 <br /> Damage To Premises Rented To You Limit $ 100, 000 Any one Premises <br /> Medical.Expense Limit $ 5,000 Anyone 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: CHAMBER OF COMMERCE <br /> LOCATION OF ALL PREMISES YOU OWN,RENT,OR OCCUPY: ❑ Location address is same as mailing address. <br /> 1. VARIOUS <br /> LINDEN CA <br /> 2. <br /> Additional locations(if any)will be shown on form S170,Commercial General Liability Coverage Part Declarations <br /> Extension. <br /> LOCATION OF JOB SITE (If Designated Projects are to be Scheduled): <br /> CODE#r:- CLASSIFICATION '' PREMIUM <br /> RATE ADVANCE <br /> Prem/Ops Prod/CompOps PREMIUM <br /> P <br /> 41670 - Clubs-civic,service or social-no buildings T+ 161 3 .573 575 <br /> or premises owned or leased except for <br /> office purposes-NFP INCLUDED INCLUDED <br /> Rate is Each Member <br /> 90556 - Special Events-Group I-Up to 500 T+ 1 77.980 78 <br /> average daily attendance INCLUDED <br /> Rate is Number of Days INCLUDED <br /> 90556 - Special Events-Group I-Up to 500 T+ 1 77.980 78 <br /> average daily attendance <br /> Rate is Number of Days INCLUDED INCLUDED <br /> 90557 - Special Events-Group 1-501-1,500 T+ 1 124.107 124 <br /> average daily attendance <br /> Rate is Number of Days INCLUDED INCLUDED <br /> * PREMIUM BASIS SYMBOLS +=Products/Completed Operations are subject to the General Aggregate Limit <br /> a =Area (per 1,000 sq.ff.of area) o =Total Operating Expenditures 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 $ 855 <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 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 /> 5150(07109) Includes copyrighted material of Insurance Services Office,Inc.with its permission. <br />