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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number: PHPK1970371 <br />Agent # 913 <br />0 See Supplemental Schedule <br />LIMITS OF INSURANCE <br />$ <br />2,000, 000 <br />General Aggregate Limit (Other Than Products —Completed Operations) <br />$ <br />2,000, 000 <br />Products/Completed Operations Aggregate Limit <br />$ <br />x, 000, 000 <br />Personal and Advertising Injury Limit (Any One Person or organization) <br />$ <br />1, 000,000 <br />Each Occurrence Limit <br />$ <br />ioo, 000 <br />Rented To You Limit (Any One Premises) <br />$ <br />5, 000 <br />Medical Expense Limit (Any One Person) <br />FORM OF BUSINESS: NON PROFIT ORGANIZATION <br />Business Description: Non Profit Organization <br />Location of All Premises You Own, Rent or Occupy: SEE SCHEDULE ATTACHED <br />AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STATED: This DolicV Is not subiect to Dremium a irlit. <br />Classifications Code No, <br />Premium <br />Basis <br />Rates <br />Prom./ Prod/ <br />ops. Comp. ops <br />Advance Premiums <br />Prem./ Prodd <br />ops. Comp, o s. <br />SEE SCHEDULE ATTACHED <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br />$ 874.00 <br />$ <br />RETROACTIVE DATE (CG 00 02 ONLY) <br />This insurance does not apply to "Bodily Injury", "Property Damage", or "Personal and Advertising Injury" which <br />occurs before the retroactive date, if any, shown below. <br />Retroactive Date: NONE <br />FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: j{er Tg Formc 5 .hedule <br />Countersignature Date Authorized Representative <br />