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<br />Philadelphia Indemnity Insurance Company <br /> <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number: PHPK141731 <br /> <br />181 See Supplemental Schedule <br /> <br />LIMITS OF INSURANCE <br />$ 1,000,000 General Aggregate limit (Other Than Products - Completed Operations) <br />$ 1 , 000 , 000 Products/Completed Operations Aggregate limit (Any One Person Or Organization) <br />$ 1,000,000 Personal and Advertising Injury limit <br />$ 1, 000 , 000 Each Occurrence limit <br />$ 100,000 Damage To Premises Rented To You limit (Any One Premises) <br />$ 5,000 Medical Expense limit (Any One Person) <br /> <br />FORM OF BUSINESS: NON PROFIT ORGANIZATION <br /> <br />Business Description: Non Profit Organization <br /> <br />Agent # 17921 <br /> <br />location of All Premises You Own, Rent or Occupy: <br /> <br />SEE SCHEDULE ATTACHED <br /> <br />Code No. <br /> <br />Premium <br />Basis <br /> <br /> <br />Rates <br /> <br />Advance Premiums <br /> <br />AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STAT D: N/A <br /> <br />Classifications <br /> <br /> <br />PremJ <br /> <br />ProdJ <br />Com .0 <br /> <br /> <br />SEE SCHEDULE ATTACHED <br /> <br />..._~._-j- <br /> <br />LaG: <br />A'>~i5H <br /> <br /> <br />"".V <br />. '.~ j <br /> <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br /> <br />$163.00 <br /> <br />$ <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 /> <br />Retroactive Date: <br /> <br />FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br /> <br />Countersignature Date <br /> <br />Authorized Representative <br />