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DocuSign Envelope ID: 699B3D1 6-OE45-49CE-A743-3OA41 OD5FOC4 <br />It <br />11�jr PENN NATIONAL COMMERCIAL GENERAL LIABILITY POLICY DECLARATIONS <br />F0 INSURANCE -. ICCURRENCE POLICY <br />RENEWAL OF GL9 0733918 <br />Panrq%gria Naliord W"I Casualty Irannon Company <br />Pain Natiwml Serudly Insuramp Company <br />P.O. Box 2361 - Hwilshug. PA 17145 <br />n1nhI— AC4ZPccAAI F: THIS POLICY IS SUBJECT TO A GENERAL AGGREGATE LIMIT <br />POLICY NUMBER <br />FROIA POLICY PERIOD <br />Tn <br />COVERAGE IS PROVIDED IN <br />AGENCY <br />JqR <br />GL9 <br />0733918 <br />01/31/18 <br />01/31/19 <br />PA NATIONAL MUTUAL CAS INS CO <br />000061825 <br />N <br />013 <br />NAMED INSURED AND ADDRESS <br />AGENCY <br />NICE <br />AND GREEN <br />COMMERCIAL <br />THE HARPER AGENCY -RO <br />FLOOR <br />CARE SERV <br />1037 S MAIN ST <br />2108 <br />QUAKENBUSH Rd <br />BURLINGTON INC 27215 <br />SNOW <br />CAMP NC <br />27349 <br />POLICY PERIOD: POLICY COVERS FROM: 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE INSURED STATED A8UVE. <br />FORM OF BUSINESS. CORPORATION BUSINESS DESCRIPTION: CARPET, RUG, FURNITURE OR UPHO <br />IN RETURN FOR PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH <br />YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />LIMITS OF INSURANCE <br />General Aggregate Limit <br />(Other than products - completed operations) $ 2,000,000 <br />Products - Completed Operations Aggregate Limit $ 2,000,000 <br />Personal and Advertising Injury Limit - Any one person or organization $ 1 , 000,000 <br />Each Occurrence Limit $ 1, 0 0 0, 0 0 0 <br />Damage to Premises Rented to you Limit - Any one premises $ 1 '000.000 <br />Medical Expense Limit -- Any one person $ 5,000 <br />PREMIUM INFORMATION <br />PREMISES NO. 1 : 2108 QUAKENBUSH RD <br />SNOW CAMP NC 27349 <br />RATES ADVANCE PREMIUM <br />CODE: PREMIUM BASIS PER PREMS /OPS PRODUCTS PREMS /OPS PRODUCTS <br />91405 24,800 PAYROLL 1000 VARIOUS INCLUDED <br />CARPET,RUG,FURNITURE OR UPHOLSTERY CLEANING - ON CUSTOMERS <br />PREMISES <br />PRODUCTS - COMPLETED OPERATIONS SUBJECT TO GENERAL AGGREGATE LIMIT <br />g C�'MIA 013 <br />T h T iB 0 <br />JAN <br />APPLICABLE TO THIS COVERAGE PART. <br />SEE ATTACHED FORMS SCHEDULE, FORM 71 -1084 <br />COUNTERSIGNED BY: <br />Authorized Representative <br />THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART COVERAGE FORKS), <br />AND FORMS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. <br />71 0029 0500 INSURED ISSUED 01/04/18 <br />RISK <br />TYPE <br />RISK <br />CLASS <br />TMC <br />SIC CODE <br />CINSL*A. <br />UN0. <br />TEAM <br />2 <br />2 <br />99 <br />N <br />013 <br />COUNTERSIGNED BY: <br />Authorized Representative <br />THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART COVERAGE FORKS), <br />AND FORMS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. <br />71 0029 0500 INSURED ISSUED 01/04/18 <br />