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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number: PHPK430634 <br />® See Supplemental Schedule <br />LIMITS OF INSURANCE <br />$3,000,000 <br />$3,000,000 <br />$1,000,000 <br />$1,000,000 <br />$100,000 <br />$2,500 <br />Agent # 6039 <br />General Aggregate Limit (Other Than Products — Completed Operations) <br />Products /Completed Operations Aggregate Limit (Any One Person Or Organization) <br />Personal and Advertising Injury Limit <br />Each Occurrence Limit <br />Rented To You Limit <br />Medical Expense Limit (Any One Person) <br />FORM OF BUSINESS: INDIV <br />Business Description: Individual <br />Location of All Premises You Own, Rent or Occupy: <br />AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STATED: <br />SEE SCHEDULE ATTACHED <br />Classifications Code No. <br />Premium <br />Basis <br />Rates <br />Prem./ Ops. Prod./ <br />Comp. Ops <br />I Advance Premiums <br />Prem./ Prod./ <br />Ops. Comp. Ops. <br />SEE SCHEDULE ATTACHED <br />TOTAL PREMIUM FOR THIS COVERAGE PART: $122.00 INCLUDED <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 />Retroactive Date: <br />FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br />Countersignature Date Authorized Representative <br />