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AXI <br /> !j <br /> COMMERCIAL EXCESS LIABILITY DECLARATIONS <br /> Policy Number- AXXS05100447-13 <br /> Renewal of-AXXSO4100447-12 <br /> AXIS Insurance Company <br /> 303 West Madison, Suite 500, Chicago, IL 60606 <br /> (312)977-0700 <br /> NAMED INSURED AND MAILING ADDRESS AGENT NAME AND ADDRESS <br /> Disabled Sports USA, Inc. American Specialty Insurance& Risk Services, Inc. <br /> 451 Hungerford Drive, Suite 100 dba A.S I R.S I Insurance Agency,American <br /> Rockville, MD 20850 Specialty Insurance & Risk Services Agency, and <br /> A S Insurance & Risk Services Agency <br /> 142 N Main Street, P O Box 309 <br /> Roanoke, IN 46783-0309 <br /> AGENT NO AE101 <br /> POLICY PERIOD FROM 12/01/13 TO' 12/01/14 <br /> AT 12 01 A.M STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. <br /> IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS <br /> POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY <br /> Excess Policy-Limits Of Insurance <br /> Each Occurrence Limit $5,000,000 <br /> Aggregate Limit $5,000,000 Per Club <br /> Other $N/A <br /> Excess Policy-Premium <br /> Premium (including premium subject to audit) $ <br /> State Tax or Other(If applicable) $N/A <br /> Premium Shown is Payable <br /> At Inception $ <br /> Audit Period If Applicable) ❑ Annually ❑ Semi-Annually ❑-Quarterly I ❑ Month) <br /> Endorsements Attached To The Excess Policy <br /> See Listing of Forms and Endorsements Forming a Part of this Policy (AXIS 0002) <br /> Countersigned N-44V--, <br /> Date. October 30 2013 By' <br /> Authorized F epresentative <br /> THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE <br /> COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS, IF <br /> ANY,COMPLETE THE ABOVE NUMBERED POLICY <br /> Issued by- CM October 30, 2013 <br /> XS DEC0001(01/09) Page 1 of 2 <br />