SAMPLE. Commercial Liability Coverage Part $ Liquor Liability Coverage Part $ See Endorsement EOD (1/95)

Transcription

1 NEW Renewal of Number POLICY DECLARATIONS No. CL NAMED INSURED AND ADDRESS: Test 123 Main Street New York, NY United States Liability Insurance Company 1190 Devon Park Drive, Wayne, Pennsylvania A Member Company of United States Liability Insurance Group Direct Bill Policy NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK STATE INSURANCE DEPARTMENT. HOWEVER, SUCH FORMS AND RATES MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. POLICY PERIOD: (MO. DAY YR.) From: 09/05/2015 To: 09/07/2015 FORM OF BUSINESS: Individual BUSINESS DESCRIPTION: Special Event 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Liability Coverage Part $ Liquor Liability Coverage Part $45.00 TOTAL: $ Coverage Form(s) and Endorsement(s) made a part of this policy at time of issue See Endorsement EOD (1/95) Agent: (223) Issued: 09/01/2015 9:01 AM Broker: HOME OFFICE - B 1190 Devon Park Drive South By: Authorized Representative Wayne, PA THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, UPD (08-07) COMPLETE THE ABOVE NUMBERED POLICY. (Free Trade Zone Statistical Code )

2 EXTENSION OF DECLARATIONS Policy No. CL Effective Date: 09/05/2015 FORMS AND ENDORSEMENTS The following forms apply to multiple coverage parts Endt# Revised Description of Endorsements CG2173 IL0017 IL0268 L-224NY 01/08 11/98 01/11 06/11 Exclusion Of Certified Acts Of Terrorism Common Policy Conditions New York Changes - Cancellation And Nonrenewal Punitive Or Exemplary Damages Exclusion L /04 Warranty Endorsement - Equal Or Greater General Liability Limit L /02 Exclusion - Products- Completed Operations Hazard L /11 Exclusion For Climbing, Rebounding And Interactive Games And Devices L /11 Exclusion For Firearms, Fireworks And Other Pyrotechnic Devices L /11 Animal Exclusion L /09 Host/Special Event Coverage Form Change Endorsement L /06 Extension Of Coverage - Committee Members LLQ368 08/10 Separation Of Insureds Clarification Endorsement ME Jacket 09/10 The Main Event Special Event Commercial Liability Policy Jacket NTE NY 01/15 Notice Of Terrorism Exclusion SPE 305 Special Jewelry Coverage Endorsement IL /02 Nuclear Energy Liability Exclusion Endorsement L /06 Exclusion - Mechanical Rides L-610NY 01/07 Expanded Definition Of Bodily Injury - New York LLQ100 07/06 Amendatory Endorsement LLQ101 08/06 Expanded Definition Of Employee LLQ102 08/06 Event Vendor/Exhibitor & Contractor- Exclusion The following forms apply to the Commercial Liability coverage part Endt# Revised Description of Endorsements CG0001 CG0068 CG0163 CG2011 CG /07 05/09 07/11 04/13 03/05 Commercial General Liability Coverage Form Recording And Distribution Of Material Or Information In Violation Of Law Exclusion New York Changes - Commercial General Liability Coverage Form Additional Insured-Managers or Lessors of Premises Exclusion - New Entities L /11 Exclusion For Structure Collapse L /08 Exclusion - Injury To Performers Or Entertainers L /09 Exclusion - Participation In Athletic Activity, Physical Activity Or Sports L /12 Absolute Exclusion for Pollution, Organic Pathogen, Silica, Asbestos and Lead with a Hostile Fire Exception L /12 Absolute Exclusion for Liquor and Other Related Liability L-721NY 02/09 New York Changes SPE /09 Special Events Property Damage Amendment EOD (01/95) All other terms and conditions remain unchanged. Page 1 of 2

3 FORMS AND ENDORSEMENTS EXTENSION OF DECLARATIONS Policy No. CL Effective Date: 09/05/2015 SPE 305 SPE 306 SPE 307 SPE 308 SPE 309 SPE 310 CG2139 CG2144 CG2147 CG /12 11/12 11/12 10/93 07/98 12/07 10/91 Special Jewelry Coverage Endorsement Cancellation or Postponement Coverage Lost Deposit Coverage Event Gift Coverage Endorsement Wedding Attire Coverage Photography And Video Coverage Endorsement Contractual Liability Limitation Limitation Of Coverage To Designated Premises Or Project Employment-Related Practices Exclusion L /06 Exclusion - Mechanical Rides New York Changes - Transfer Of Duties When A Limit Of Insurance Is Used Up The following forms apply to the Liquor Liability coverage part Endt# Revised Description of Endorsements CG2603 CG2635 L-618CNY 04/09 12/93 08/11 New York Changes - Liquor Liability Coverage Form New York Changes - Transfer Of Duties When A Limit Of Insurance Is Used Up Amendment Of Premium Audit Conditions - New York L /11 Absolute Pollution Exclusion - Liability LQ /08 Event Vendor - Other Insurance LQ /09 Limitation Of Coverage To Insured Premises SPE 305 Special Jewelry Coverage Endorsement CG /07 Liquor Liability Coverage Form L /06 Exclusion - Mechanical Rides L /10 Additional Insured - Manager Or Lessors Of Premises EOD (01/95) All other terms and conditions remain unchanged. Page 2 of 2

4 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Policy No. CL Effective Date: 09/05/2015 LIMITS OF INSURANCE Each Occurrence Limit $1,000,000 Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000 Medical Expense Limit (Any One Person) $1,000 Damages To Premises Rented To You (Any One Premises) $100,000 Products/Completed Operations Aggregate Limit See See L-535 General Aggregate Limit $2,000,000 Event Gift Coverage Limit $5,000 Special Jewelry Coverage Limit $8,800 Lost Deposit Coverage Limit $6,000 Wedding Attire Coverage Limit $8,000 Cancellation or Postponement Coverage Limit $45,000 Photography and Video Coverage Limit $8,000 LIABILITY DEDUCTIBLE $0 LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Location Address Territory 1 Test Venue 987 Bayshore Drive, New York, NY PREMIUM COMPUTATION Advance Premium Evt # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other 1 Wedding (applicant is the host of the event) Attendees N/A N/A $250 1 Additional Insured - Managers or Lessors of Premises Per Additional Insured N/A N/A $0 1 Event Gift Coverage Per Event N/A N/A $25 1 Special Jewelry Coverage Per Event N/A N/A $26 1 Lost Deposit Coverage Per Event N/A N/A $25 1 Wedding Attire Coverage Per Event N/A N/A $21 1 Cancellation or Postponement Coverage Per Event N/A N/A $135 1 Photography and Video Coverage Per Event N/A N/A $24 MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $1 TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART: (This Premium may be subject to adjustment.) MP - minimum premium $506 Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue: See Form EOD (01/95) and Form SOE (03/10) THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission. CL150 (10/03) Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988 Page 1 Of 1

5 LIQUOR LIABILITY COVERAGE PART DECLARATIONS Policy No. CL Effective Date: 09/05/2015 LIMITS OF INSURANCE Liquor Each Common Cause Limit $1,000,000 Liquor Aggregate Limit $2,000,000 LIABILITY DEDUCTIBLE $0 LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Location Address Territory 1 Test Venue 987 Bayshore Drive, New York, NY PREMIUM COMPUTATION Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue: See Form EOD (01/95) and Form SOE (03/10) Advance Premium Evt # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other 1 Wedding (applicant is the host of the event) Consumers N/A N/A $45 1 Additional Insured - Managers or Lessors of Premises Per Additional Insured TOTAL PREMIUM FOR LIQUOR LIABILITY COVERAGE PART: (This Premium may be subject to adjustment.) MP - minimum premium N/A N/A $0 $45 THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission. LQ 150 (02/09) Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988 Page 1 Of 1

6 Event Location(s): Test Venue 987 Bayshore Drive, New York, NY EXTENSION OF DECLARATIONS Regardless of the dates shown on the Declarations, this insurance applies only for the location(s), event(s) and date(s) specified in this Extension of Declarations. Policy No. CL SCHEDULE OF EVENTS Start Date End Date Wedding (applicant is the host of the event) 09/05/ /05/2015 Subject to the terms and conditions of this policy, coverage is provided for a maximum of twenty-four (24) hours after the scheduled end date of an event shown above. THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. SOE (03/10) All other terms and conditions remain unchanged. Page 1 of 1

7 POLICY NUMBER: CL COMMERCIAL GENERAL LIABILITY CG THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person(s) Or Organization(s) (Additional Insured): Effective Date: 09/05/2015 Test Venue 987 Bayshore Drive New York, NY Designation of Premises (Part Leased To You): Test Venue 987 Bayshore Drive New York, NY Additional Premium: $ A. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: Any "occurrence" which takes place after you cease to be a tenant in that premises. Structural alterations, new construction or demolition operations performed by or on behalf of the person (s) or organization(s) shown in the Schedule. However: The insurance afforded to such additional insured only applies to the extent permitted by law; and B. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amout of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG Insurance Services Office, Inc., 2012 Page 1 Of 1