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NAUTILUS INSURANCE COMPANY <br />COMMERCIAL GENERAL LIABILITY 0OVERAGE PART DECLARATIONS <br />onI ICYNUMBER: NC731770 «__.>. n .e• , n_n 12.01 A.M. Standard Time <br />6cten510n Of Declarations 15 attached. uo+..nry <br />LIMITS OF INSURANCE ❑ If box is checked, refer to f ran S132 for Limits of Insurance. <br />Aggregate limit (Other Than Products/Completed eratioms) $ 2 000.000 <br />General 2,000,000 <br />products/Completed Operations Aggregate Limes $ <br />2,000,000 Any One Person Or Organization <br />Personal and Advertising Injury Limit <br />$ z 000,090 <br />Each Occurrence Limit <br />Damage To Premises Rented To You Limit E 100 000 Any one Premises <br />$ 5. 000 Anyone Person <br />Medical Expense Limit <br />RETROACTIVE DATE JCG 00 02 ONL <br />"bodily injury", "property da age" or "personal and advertising injury' which occurs <br />This insurance does not apply to <br />before the Retroactive Date, if any, shown here: NONE _ (Enter Date or "NONE" if no Retroactive Date applies) <br />BUSINESS DESCRIPTION AND LOCATION OF PREMISES s <br />BUSINESS DESCRIPTION: <br />LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCC4PY: ❑ Location address is same as mailing address. <br />1.5507 WINDWARD AVE LONG BEACH, CA 90614 <br />2. i <br />Additional locations (if any) will be shown on form 8170. <br />LOCATION OF JOB SITE (If Designated Projects are to be S�heduled): <br />PREMIUM <br />RATE <br />ADVANCE <br />CODE # CLASSIFICATION <br />* <br />BASIS <br />PR/CO <br />All Other <br />PREMIUM <br />41667 CLUBS, SERVICE OR SOCIAL <br />p <br />33,600 <br />INCL '2.436 <br />!� <br />1 <br />1,500 <br />HAVING BUILDING OR <br />PREMISES OWNED OR LEASED <br />OTHER TITAN -NOT FOR- <br />i <br />PROFIT -INCL. PRODUCTS <br />AND/OR COMPLETED OPER. <br />THESE PRODUCTS -COMPLETED <br />OPERATIONS ARE SUBJECT <br />TO THE GENERAL AGGREGATE <br />LIMIT. <br />i <br />49950 BLANKET ADDITIONAL <br />e <br />1 <br />!FLAT <br />250 <br />INSURED CHARGE UP TO 10 <br />i <br />t = Products/Completed Operations are subject to the General Aggregate Limit <br />PREMIUM BASIS SYMBOLS <br />o =Total Operating Ex enses S = Gross Sales (par 31,OOD of Gross Sales) <br />a =Area (per 1,o00 sq. ft. of area) <br />c = Total Cost (per $1,000 of Total Cost) (per $1,000 Total O acing Expenditures) t = Sae Classification <br />m= Admissions (pet l.000Adm,swona = Payroll (per $1,000 Pa roll u = Units r unit <br />P EMIUM FOR THIS COVERAGE PART 1, 750.00 <br />FORMS AND ENDORSEMENTS other than applicable Forms and Endorsements shown elsewhere in the policy) <br />Forms and Endorsements applying to this Coverage Part and'ymade part of this policy al time of Issue. <br />Refer to S902 Schedule of FDrms and Endorsements <br />n.¢ nF TUF in15L1RFO AND THE POLICY PERIOD. <br />THESE DECLARATIONS ARE PART OF THE PUDUT uecr.xnn - perm - <br />Includes Copyrighted material of Insurance S 'ccs Office, Inc, with its permission, <br />5150 (10104) Copyright I50 Prop es, Inc,, 2000 <br />-INSURED-1 <br />