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Capitol Specialty Insurance Corp <br />P.O. Box 5900, Madison, WI 53705 <br />POLICY COVERAGE PART <br />FORM SCHEDULE <br />POLICY NUMBER POLICY PERIOD AGENCY <br />BR01292559 03/26/2009 03/26/2010 04608 <br />NAMED INSURED AND ADDRESS AGENT <br />EARTHTECK INTERNATIONAL CORP <br />PO Box 48259 BASS UNDERWRITERS INC <br />Los Angeles, CA 90048-0259 <br />(Los Angeles CTY) <br />Forms and Endorsements applying to this Coverage Part and made a part of this policy at time of issue: <br />FORMS APPLICABLE TO ALL PREMISES AND COVERAGES <br />Form Edition Description <br />CICG 174 0708 Common Policy Declarations <br />CGE 064 0208 Notice -Offer of Terrorism Coverage <br />CGE 112 0496 Important Notice! <br />CGE 263 0307 Policyholder Audit Information <br />CGE 067 0803 Additional Interest Schedule <br />CICG 176 1093 Location Schedule <br />CGE 126 1004 Amendment-Minimum Earned Premium <br />CGE 071 0306 Service of Suit <br />IL 00 17 1198 Common Policy Conditions <br />IL 00 21 0498 Nuclear Energy Liability Exclusion Endorsement <br />IL 09 85 0108 Disclosure Pursuant to Terrorism Risk Insurance Act <br />BJP190 0306 Commercial Lines Policy Jacket <br />CICG 179 (01-08) Insured Copy <br />