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<br />Stoc k <br />Company <br />COM M ERCIAL GENERAL LIABILITY COVERAGE PART <br />SUPPLEM ENTAL DECLARATIONS <br /> <br /> <br /> <br /> <br />DQW1164694 <br />POLICY NUMBER: <br /> <br />IB\[!SFOUBM!DFOUFS!MMD <br /> <br />NAMED INSURED: <br /> <br /> <br />NO. <br /> <br />LOCATIONS of all premises you Own, Rent, or Occupy <br /> <br />32 <br />24142!Ofxmboe!Tu-!Hbsefo!Hspwf-!DB!:3955 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />CLASS PREMIUM BASIS. RATES ADVANCE PREMIUM <br /> <br />NO. <br /> <br />Code / ExposureProd/ CO All Other Prod/ CO All Other <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Tff!Gpsn!T3111 <br /> <br />Total Premium This Page $ <br /> <br />gps!Upubm!Qsfnjvn <br /> <br />Ac c umulative Total $ <br /> <br />(s) gross sales - per $1000 (c) total cost - per $1000 (m ) adm issions - per 1000 (e) each <br />(p) payroll - per $1000 (a) area - per 1000 sq. ft. (u) units <br /> <br />Polic y may be AUDITABLE <br /> <br /> <br />SPECIFIC GENERAL LIABILITY FORMS/ ENDORSEMENTS <br /> <br /> <br />This page alone does not provide c overage and must be attac hed to a Commerc ial Lines Common Polic y Dec larations <br /> <br />Common Polic y Conditions, Coverage Part Coverage Form(s) and any other applic able forms and endorsements. <br />S2001 (10/ 2013) <br />Qbhfpg3 <br />3 <br /> <br />