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NAUTILUS INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS OLICY NUMBER: Nc731770 ffective Date: 10 -10 -07 12:01 A.M. Standard Time Extension of Declarations Is attached. LIMITS OF INSURANCE ❑ If box is checked, refer to f nn S132 for Limits of Insurance. General Aggregate Limit (Other Than Products/Completed erations) $ 2 000, 000 Products/Completed Operations Aggregate Limit $ 00o 2 000, Any one Person or organization Personal and Advertising Injury Limit ; Each Occurrence Limit $ 2 000,000 Damage To Premises Rented To You Limit $ 100, 000 Any One Premises Medical Expense Limit $ 5,000 Any One Person RETROACTIVE DATE CG 00 02 ONLY) This insurance does not apply to "bodily injury", "property dajnage" or "personal and advertising injury" which occurs before the Retroactive Date, if any, shown here: NONE r (Enter Date or "NONE" if no Retroactive Date applies) BUSINESS DESCRIPTION AND LOCATION OF PREMISES s BUSINESS DESCRIPTION: LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCCLIPY: ❑ Location address is same as mailing address. 1. 5507 WINDWARD AVE LONG BEACH, CA 90814 2. Additional locations (if any) will be shown on form S170. LOCATION OF JOB SITE (If Designated Projects are to be S�heduled): iPREMIUM RATE ADVANCE CODE # CLASSIFICATION * BASIS PR /CO All Other PREMIUM 41667 CLUBS, SERVICE OR SOCIAL P 33,600 INCL 2.436 1,500 HAVING BUILDING OR PREMISES OWNED OR LEASED OTHER THAN -NOT FOR - PROFIT -INCL. PRODUCTS AND /OR COMPLETED OPER. THESE PRODUCTS - COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT. 49950 BLANKET ADDITIONAL e i 1 FLAT 250 INSURED CHARGE UP TO 10 f PREMIUM BASIS SYMBOLS + = Products /Completed Operations are subject to the General Aggregate Limit a =Area (per 1,000 sq. ft. or area) o =Total Operating Ex enses s =Gross Sales (per $1,000 or Gross sales) c = Total Cast (per $1,000 of Total Cost) (per $1,000 Total Op acing Expenditwes) t = See Classification m = Admissions er 1,000 Admissions =Payroll (per $1,000 if Payroll) u = Units (per unit PREMIUM FOR THIS COVERAGE PART$ 1,750.00 FORMS AND ENDORSEMENTS other than applicable Forms abed Endorsements shown elsewhere in the policy) Forms and Endorsements applying to this Coverage Part andmade part of this policy at time of Issue: Refer to S902 Schedule of Forms and Endorsements THE POLICY cpRinn THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS C04TAINING THE NAME OF THE INSURED AND Includes copyrighted material of Inswance S*vIces Office, Inc. with its permission. S150 (10 104) Copyright ISO Props Ies, Inc., 2000 - INSURED -;