COMMERCIAL GENERAL LIABILITY SECTION DATE …

OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state business auto SECTION , acord 137) COMMERCIAL GENERAL LIABILITYOWNER'S & CONTRACTOR'S PROTECTIVECLAIMS MADEOCCURRENCEDEDUCTIBLESPROPERTY DAMAGE$BODILY INJURY$$PERCLAIMPEROCCURRENCEPREMIUMSPRE MISES/OPERATIONSPRODUCTSOTHERTOTALLIMITS COVERAGES$$$$$$$EMPLOYEE BENEFITSMEDICAL EXPENSE (Any one person)DAMAGE TO RENTED PREMISES (each occurrence)EACH OCCURRENCEPERSONAL & ADVERTISING INJURYPRODUCTS & COMPLETED OPERATIONS AGGREGATEGENERAL AGGREGATEAGENCYPHONE(A/C, No, Ext):FAX(A/C, No):SUB CODE:CODE:AGENCYCUSTOMER ID:USE ONLYCOMPANYFORAUDITPAYMENT PLANEFFECTIVE DATEEXPIRATION DATEAGENCY BILLDIRECT BILLI nsured)Named(FirstAPPLICANTSCHEDULE OF HAZARDSRATEPREM/OPSPRODUCTSPREMIUMPREM/O PSPRODUCTSRATING AND PREMIUM BASIS(S) GROSS SALES - PER $1,000/SALES(P) PAYROLL - PER $1,000/PAY(A) AREA - PER 1,000/SQ FT(C) TOTAL COST - PER $1,000/COST(M) ADMISSIONS - PER 1,000/ADM(U) UNIT - PER UNIT(T) OTHER#HAZEXPOSURETERRBASISPREMIUMCODECLA SSCLASSIFICATION#LOCCOMMERCIAL GENERAL LIABILITY SECTIONDATE (MM/DD/YYYY)REMARKSCLAIMS MADE (Explain all "Yes" responses)1.

OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)

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