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COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />;Y NUMBER: NC521567 <br />nnnInn, 4 rtAHr rnfinnq is nih;nhAd Effective Data: 05/02t2019 12:01 A.M. Standard <br />General Aggregate Limit (Other Than Products/Completed Operations) $-2--i.M09-L-000 <br />Products/Completed Operations Aggregate Limit <br />$ r <br />Inr, 7. uded <br />Personal and Advertising Injury Limit <br />$ --1i.-000,000 <br />Any One Person Or Organizatik <br />Each Occurrence Limit <br />$ <br />1,000,000 <br />Damage To Premises Ranted To You Limit <br />$ <br />1eo, 000' Any One Premises <br />Medical Expense Limit <br />$ <br />5,0000 Any One person <br />ITROACTIVE DATE CG _q�02 ONLY <br />This Insurance (Ices not apply to "bodily injury", "property <br />damage" or "personal <br />and advertising injury' which occurs <br />before the Retroactive Date,±enLsbowLhane: <br />(Enter Date or <br />"NONE" If no Retroactive Date applies <br />BUSINESS DESCRIPTION: INSTRUCTOR <br />LOCATION OF ALL PREMISES YOU ffl, RENT, 013 OCCUPY: 9 Location address is same as mailing address, <br />26741 PORTOLASUTTF 1E 833, 000THILL RANCH, CA 9260 <br />1 <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!/ - CLASSIFICATION <br />SAFETY/UMERCIUNCY INSTRUCTOR rated <br />74'14 - as Schools - frnds or vocational <br />Additional Insured - owners, <br />90608 . Lessees or Contxactora Automatic <br />Status When Required in <br />Coriotxuetion Agreement With You <br />Rl.anket - Primary and <br />90656 , NonconLribllLory (111cluding <br />Completed Ormxations) <br />90657 . Waiver of Transfer of Rights <br />Against Othern, to 13,-, Ui1anketi <br />PREMIUM <br />rc <br />BASIS�preeniOps <br />kF 30 50.010 <br />1 1 1,50. 000 <br />1. 1 150.0 <br />1 200.000 <br />1,500 <br />Incl.udedlEncluded <br />150 <br />1,50 <br />200 <br />PREMIUM BASIS SYMBOLS + w Products/Completed Operations are subject to the General Aggregate Limit <br />a = Arco (per 1;000 sq. ft. of arch) 0 = Total 0 orating Expenditures s = Gross Sales (per $1,000 of Gross <br />c = Total Coot (liar $1.000 of Total Cost) (per $1,900 Total Operating Expenditures) I = See Classification <br />m=Admissions (Der 1.00()Adrnlsslonsl n =Pavroll fioer$1.000ol'Pavroll) u = Units loer unit( <br />PREMIUM FOR T111S COVERAGE PART <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 />S 150 (07109) Includes copyrighted material of Insurance Services Office, Inc. with its pormission, <br />21000 <br />