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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number. PHPK196567 <br />® See Supplemental Schedule <br />Agent # 17921 <br />LIMITS OF INSURANCE <br />$ 1, 0 0 0 , 0 0 o General Aggregate Limit (Other Than Products -Completed Operations) <br />$ i , 0 00 , 0 0 o Products/Completed Operations Aggregate Limit (Any One Person Or Organization) <br />$ i, ooo, ooo personal and Advertising Injury Limit <br />$ i, ooo, ooo Each Occurrence Limit <br />$ 100, ooo Damage To Premises Rented To You Limit (Any One Premises) <br />$ 5, ooo 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: N/A <br />- I Rates <br />Premium PremJ Prod./ <br />SEE SCHEDULE ATTACHED ~ _ _L,,,,c~"i ~ Ix>s ~ -~ <br />_...--- <br />. SAO ,GK <br />~;tty Atton <br />Cz.~k <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br />J <br />Advance Premiums <br />Prem./ Prod) <br /> <br />~$ 167 00 I$ <br />RETROACTNE 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: <br />FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br />Courrtersignature Date Authorized Representative <br />