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000vSign Envelope ID: 3o8AuC3C'e4r7-4s3e-880E-5n83Cnurr18A <br /> Change Date: 11/11/2015 <br /> Philadelphia Indemnity Insurance Company <br /> COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br /> Policy Number: PHPK1396797 <br /> Agent# 1558 <br /> I See Supplemental Schedule <br /> LIMITS OF INSURANCE <br /> 3' 000' 000 General Aggregate Limit (Other Than Products—Completed Operations) <br /> � 3' 000' COO Products/Completed Operations Aggregate Limit (Any One Person Or Organization) <br /> � z' 000' nno Personal and Advertising Injury Limit <br /> � 1' ouo. 000 Each Occurrence Limit <br /> � <br /> 100, on Rented To You Limit <br /> � <br /> 5, 000 Medical Expense Limit (Any One Person) <br /> FORM OF BUSINESS: CORPORATION <br /> Business Description: Non Profit Organization <br /> Location of All Premises You Own, Rent or Occupy: SEE SCHEDULE ATTACHED <br /> AUDIT PERhOQ,ANNUAL. UNLESS OTHERV8SESTATED: This poUcyis not subject to premium audit. <br /> Rates / Advance Premiums <br /> Premium Prom/ Prod./ Prem./ Prod./ <br /> Classifications Code No. Basis Ops. Comp.Ops Ops. Comp.Ops. <br /> SEE SCHEDULE ATTACHED <br /> TOTAL PREMIUM FOR THIS COVERAGE PART: $ 317.00 $ <br /> . <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 dete, if any, shown below. <br /> Retroactive Date: NONE <br /> FORM (S)AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br /> Countersignature Date Authorized Representative <br />