GENERAL LIABILITY NOTICE OF …

1 DATE (MM/DD/YYYY)AGENCYPREVIOUSLYPHONEDATE OF OCCURRENCE AND TIMEDATE OF CLAIM(A/C, No, Ext):REPORTEDEFFECTIVE DATEEXPIRATION DATEPOLICY TYPERETROACTIVE DATECOMPANYMISCELLANEOUS INFO (Site & location code)NAIC CODE:FAX(A/C, No):E-MAILADDRESS:POLICY NUMBERREFERENCE NUMBERCODE:SUB CODE:AGENCYCUSTOMER ID:NAME AND ADDRESSNAME AND ADDRESSWHERE TO CONTACTSOC SEC # OR FEIN:WHEN TO CONTACTE-MAILE-MAILADDRESS:ADDRESS:RESID ENCE PHONE (A/C, No)BUSINESS PHONE (A/C, No, Ext)RESIDENCE PHONE (A/C, No)BUSINESS PHONE (A/C, No, Ext)AUTHORITY CONTACTEDLOCATION OFOCCURRENCE(Include city & state)DESCRIPTION OFOCCURRENCE(Use separate sheet,if necessary)COVERAGE PART ORFORMS (Insert form#s and edition dates) GENERAL AGGREGATEPROD/COMP OP AGGPERS & ADV INJEACH OCCURRENCEFIRE DAMAGEMEDICAL EXPENSEDEDUCTIBLEUMBRELLA/CARRIER:LIMITS :EXCESSTYPE OF PREMISESPREMISES: INSURED ISOWNER S NAME& ADDRESS(If not insured)OWNERS PHONE(A/C, No, Ext):TYPE OF PRODUCTPRODUCTS: INSURED ISMANUFACTURER SNAME & ADDRESS(If not insured)MANUFACT PHONE(A/C, No, Ext):WHERE CAN PRODUCT BE SEEN?

2 OTHER LIABILITY IN-CLUDING COMPLETEDOPERATIONS (Explain)PHONE (A/C, No, Ext)NAME &ADDRESS(Injured/Owner)AGESEXOCCUPATIONP HONE (A/C, No, Ext)EMPLOYER SNAME &ADDRESSDESCRIBE INJURYWHERE TAKENWHAT WAS INJURED DOING?ESTIMATE AMOUNTWHEN CAN PROPERTY BE SEEN?DESCRIBEWHERE CANPROPERTYPROPERTY(Type, model, etc)BE SEEN?NAME & ADDRESSBUSINESS PHONE (A/C, No, Ext)RESIDENCE PHONE (A/C, No)REMARKSREPORTED BYREPORTED TOSIGNATURE OF INSUREDSIGNATURE OF PRODUCERNOTICE OFAMOCCURRENCENOTICE OF CLAIMPMYESNOOCCURRENCECLAIMS MADECONTACT INSUREDPDBIPERSIR/UMBRELLAEXCESSAGGRCLAI M/OCCDEDOWNERTENANTOTHER:MANUFACTURERVEN DOROTHER:FATALITYINSUREDCONTACTOCCURRENC EPOLICY INFORMATIONTYPE OF LIABILITYINJURED/PROPERTY DAMAGEDWITNESSESNOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDEACORD 3 (2005/06) ACORD CORPORATION 1986-2005 GENERAL LIABILITY NOTICE OF OCCURRENCE/CLAIMACORD 3 (2005/06)* In Florida - Third Degree FelonyFor your protection, Arizona law requires the following statement to appear on this form.

3 Any person who knowinglypresents a false or fraudulent claim for payment of a loss is subject to criminal and civil person who knowingly and with intent to defraud any insurance company or another person, files a statement ofclaim containing any materially false information, or conceals for the purpose of misleading, information concerningany fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and[NY: substantial] civil penalties. In DC, LA, ME, TN and VA, insurance benefits may also be your protection, California law requires the following to appear on this form: Any person who knowingly presents afalse or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company forthe purpose of defrauding or attempting to defraud the company.

4 Penalties may include imprisonment, fines, denial ofinsurance, and civil damages. Any insurance company or agent of an insurance company who knowingly providesfalse, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding orattempting to defraud the policy holder or claimant with regard to a settlement or award payable from insuranceproceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files aStatement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.*For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss orbenefit is a crime punishable by fines or imprisonment, or person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,incomplete, or misleading information commits a person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a to NRS , any person who knowingly and willfully files a statement of claim that contains any false,incomplete or misleading information concerning a material fact is guilty of a person who, with purpose to injure, defraud or deceive any insurance company.

5 Files a statement of claimcontaining any false, incomplete or misleading information is subject to prosecution and punishment for insurancefraud, as provided in RSA 638 person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits anapplication or files a claim containing a false or deceptive statement is guilty of insurance : Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim forthe proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a in ArizonaApplicable in Arkansas, Delaware, District of Columbia, Kentucky, Louisiana, Maine, Michigan,New Jersey, New Mexico, New York, Pennsylvania, Tennessee, Virginia and West VirginiaApplicable in CaliforniaApplicable in ColoradoApplicable in Florida and IdahoApplicable in HawaiiApplicable in IndianaApplicable in MinnesotaApplicable in NevadaApplicable in New HampshireApplicable in OhioApplicable in Oklahoma