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COMMERCIAL GENERAL LIABILITY <br /> COVERAGE PART DECLARATIONS EXTENSION <br /> POLICY NUMBER: NN502306 Effective Date: 11/01/2014 12:01 A.M. Standard Time <br /> LOCATION OF PREMISES <br /> Location of All Premises You Own, Rent or Occupy: <br /> PREMIUM <br /> PREMIUM RATE ADVANCE <br /> CODE#- CLASSIFICATION " BASIS Prem/Ops Prod/Comp PREMIUM <br /> Additional InLeresL - Per Form t+ 1 Included Included <br /> 49950 CC2011 <br /> Excluded Excluded <br /> 49950 Additional Interest - Per Form t+ 1 Included Included <br /> CG2011 <br /> Excluded Excluded <br /> PREMIUM FOR THIS COVERAGE PART $ 949 <br /> THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. <br /> S170 (07/09) Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Page 1 of 1 <br />