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CCR2018066-TCVFD InsuranceS 221294802 AGENT'S COPY AGENT'S COPY Issued by The Stock Insurance Company Policy Number COMMERCIAL POLICY COMMON DECLARATION Named Insured and Address Policy Period From: To: 12:01 A.M Standard Time At Location of Designated Premises. Named Insured is: Producer Number: Producer: S c h e d u l e o f C o v e r a g e In return for payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance indicated in the schedule above. Insurance is provided only for those coverages for which a specific limit is shown on the attached coverage declaration(s). PAYMENT METHOD Total Policy Premium (This premium may be subject to adjustment.) Date Issued: Issuing Office: Authorized Representative IL-7025 (11/89) S 2212948 APRIL 1, 2018 APRIL 1, 2019 ASSN/LABOR/RE 00-48177-00000 $33,717.00 D/B - Q APRIL 3, 2018 HEARTLAND REGION SELECTIVE INSURANCE COMPANY OF AMERICA 40 WANTAGE AVE, BRANCHVILLE, NJ 07890 COURI INSURANCE AGENCY INC WISCONSIN TESS CORNERS VOLUNTEER FIRE DEPARTMENT W144S6731 TESS CORNERS DR MUSKEGO, WI 53150-3155 COMMERCIAL PROPERTY COVERAGE COMMERCIAL GENERAL LIABILITY COVERAGE COMMERCIAL AUTOMOBILE COVERAGE COMMERCIAL INLAND MARINE COVERAGE COMMERCIAL VESP/ADMIN COVERAGE COMMERCIAL UMBRELLA COVERAGE COMMERCIAL CRIME COVERAGE PREMIUM INCLUDES TERRORISM - CERTIFIED ACTS $680.00 PREMIUM INCLUDES TERRORISM - AUTO $403.00 AGENT'S COPYAGENT'S COPY Policy Number SCHEDULE OF LOCATIONS Policy Effective Date:Schedule Effective Date: Prem. Bldg. No. Location No. Occupancy IL-7036 (01/93) S 2212948 APRIL 1, 2018 APRIL 1, 2018 1 W144S6731 TESS CORNERS DR 1 FIRE HOUSE MUSKEGO, WI 53150 2 S100W13444 LOOMIS DR 1 FIREHOUSE MUSKEGO, WI 53150 3 S76W17858 JANESVILLE RD 1 FIRE DEPT MUSKEGO, WI 53150 4 W195S10030 RACINE AVE 1 FIRE DEPARTMENT MUSKEGO, WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPY IL-7035 (08/93) Policy Number COMMERCIAL POLICY FORMS AND ENDORSEMENT SCHEDULE Policy Effective Date: Schedule Effective Date NOTICE TO POLICYHOLDER:All the forms and endorsements contained in this policy as of the “Schedule Effective Date” are listed above. Forms and endorsements added to the policy after this date will appear on a “Policy Changes” endorse- ment. Please read your policy and all “Policy Changes” carefully. NOTE: All applicable “IL” endorsements will be attached in the Common Section of the policy. S 2212948 APRIL 1, 2018 APRIL 1, 2018 THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMON COVERAGE PART: IL 70 25 1189 COMMERCIAL POLICY COMMON DECLARATION IL 70 36 0193 SCHEDULE OF LOCATIONS IL 00 03 0498 CALCULATION OF PREMIUM IL 00 17 1185 COMMON POLICY CONDITIONS IL 00 21 0908 NUCLEAR ENERGY LIABILITY EXCLUSION IL 79 15 0117 IDENTITY RECOVERY COVERAGE IL 79 56 0610 GOV ENTITY & VF ORG PARTICIPATING ENDT IL 79 90 1010 THIRD PARTY NOTICE IL 89 48 0704 EXCLUSION - LEAD HAZARD IL 89 56 0899 ASBESTOS EXCLUSION ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL PROPERTY COVERAGE PART: CP 70 26 0617 COMMERCIAL PROP DEC CP 00 10 1012 BUILDING & PERSONAL PROPERTY COVERAGE FM CP 00 30 1012 BUSINESS INCOME COVERAGE (W/EX EXP) CP 00 90 0788 COMMERCIAL PROPERTY CONDITIONS CP 01 13 1012 WISCONSIN CHANGES CP 01 40 0706 EXCL OF LOSS DUE TO VIRUS OR BACTERIA CP 10 30 1012 CAUSES OF LOSS-SPECIAL FORM CP 15 32 0607 CIVIL AUTHORITY CHANGE(S) CP 75 51 0511 SYSTEMS POWER PAC CP 75 92 0406 SYS POWER PAC EMERGENCY SERVICES CP 76 11 1011 GREENPAC ENHANCEMENT ENDORSEMENT CP 76 13 0513 CRISIS RESPONSE COVERAGE CP 76 23 1011 COMMERCIAL PROP MORTGAGE HOLDERS SCHED CP 76 30 0116 ELITEPAC PROPERTY EXT END CP 76 36 0116 EMERGENCY SERVICES ELITEPAC PROP EXT END CP 76 37 0116 ELITEPAC SCHEDULE - EMERGENCY SERVICES CP 76 63 0116 BI ACTUAL LOSS SUST ES&G - 24 MONTH LIM CP 76 64 0116 ACCOUNTS RECEIVABLE COVERAGE ENDORSEMENT CP 76 65 0116 COMMANDEERED PROPERTY COVERAGE END CP 76 66 0116 COMMUNICATIONS EQUIPMENT COVERAGE END CP 76 67 0116 ELECTRONIC INFORMATION SYSTEMS COVER END CP 76 68 0116 FINE ARTS COVERAGE ENDORSEMENT CP 76 69 0116 INSTALLATION PROPERTY COVERAGE END CP 76 70 0116 MOBILE EQUIPMENT COVERAGE END CP 76 71 0116 PERSONAL EFFECTS COVERAGE END CP 76 72 0116 PROPERTY IN TRANSIT COVERAGE END CP 76 73 0116 SALESPERSONS SAMPLES COVERAGE END CP 76 74 0116 TOOLS AND EQUIPMENT COVERAGE END CP 76 75 0116 VALUABLE PAPERS COVERAGE END IL 00 03 0908 CALCULATION OF PREMIUM IL 00 17 1198 COMMON POLICY CONDITIONS IL 02 83 0907 WISCONSIN CHANGES-CANC AND NONRENEWAL IL 09 52 0115 CAP ON LOSS FROM CERT ACTS OF TERRORISM IL 09 85A 0115 DISCL PURSUANT TO TERR RISK INS ACT ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL GENERAL LIABILITY COVERAGE PART: CG 70 35 0690 COMMERCIAL LIABILITY COVG DECLARATION CG 00 01 0413 CGL COV FORM (OCCURRENCE) CG 01 24 0193 WISCONSIN CHANGES-AMEND OF POLICIES COND CG 20 01 0413 PRIMARY AND NONCONTRIBUTORY CG 20 26 0704 ADDL INSD-DESIG PERSON OR ORGANIZATION AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY IL-7035 (08/93) Policy Number COMMERCIAL POLICY FORMS AND ENDORSEMENT SCHEDULE Policy Effective Date: Schedule Effective Date NOTICE TO POLICYHOLDER:All the forms and endorsements contained in this policy as of the “Schedule Effective Date” are listed above. Forms and endorsements added to the policy after this date will appear on a “Policy Changes” endorse- ment. Please read your policy and all “Policy Changes” carefully. NOTE: All applicable “IL” endorsements will be attached in the Common Section of the policy. S 2212948 APRIL 1, 2018 APRIL 1, 2018 THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL GENERAL LIABILITY COVERAGE PART: CG 21 06 0514 EXCL ACCESS DISCL CONF PERS INF-W/LIM BI CG 21 47 1207 EMPLOYMENT-RELATED PRACTICES EXCL CG 21 67 1204 FUNGI OR BACTERIA EXCLUSION CG 21 70 0115 CAP ON LOSSES FROM CERT ACTS OF TERROR CG 24 04 0509 WAIV OF TRNSFR RGTS OF REC AG OTH CG 24 12A 1185 BOATS-ENDORSEMENT CG 25 04 0509 DESIGNATED LOCATION(S) GENERAL AGG LIMIT CG 73 00 0116 ELITEPAC GL EXT END CG 73 04 0116 EMERG SERV AND GOV ELITEPAC GL EXT END CG 79 35A 0708 PRODUCT RECALL EXPENSE COV ENDT CG 79 95 0418 DATA COMPROMISE COVERAGE CG 79 97 1116 GENERAL AGGREGATE LIMIT PER PROJECT CG 80 30 1115 EXCLUSION-FAILURE TO SUPPLY-UTILITIES IL 00 03 0908 CALCULATION OF PREMIUM IL 00 17 1198 COMMON POLICY CONDITIONS IL 02 83 0907 WISCONSIN CHANGES-CANC AND NONRENEWAL IL 09 85A 0115 DISCL PURSUANT TO TERR RISK INS ACT IN 05 81 0216 ERISK HUB IMPORTANT NOTICE ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE BUSINESS AUTOMOBILE COVERAGE PART: CA 70 57 0292 AUTO DEC -LOSS PAYEE CA 70 58 0292 BUSINESS AUTO COVERAGE DECLARATION PAGE2 CA 00 01 0310 BUSINESS AUTO COVERAGE FORM CA 01 17 1111 WISCONSIN CHANGES CA 04 42 0310 EXCL FED EMPLOYEES USING AUTO IN GOV BUS CA 20 18 1293 PROFESSIONAL SERVICES NOT COVERED CA 20 54 1001 EMPLOYEE HIRED AUTOS CA 21 03A 1111 WISCONSIN UNINSURED MOTORISTS COVERAGE CA 21 45 1111 WISCONSIN UNDERINSURED MOTOR COVERAGE CA 70 27 0416 VALUE GUARD COVERAGE-FIRE DEPARTMENTS CA 70 38 0790 PHYSICAL DAMAGE COVERAGE CA 77 74 0706 LIMITED MOBILE EQUIPMENT COVERAGE CA 78 09 0116 ELITEPAC COMMERCIAL AUTO EXT END CA 78 10 0116 EMERG SERV AND GOV ELITEPAC AUTO EXT END CA 78 19 0116 COMM AUTO ELITEPAC SCH - EMERG SERV GOV CA 99 24 1111 AUTO MEDICAL PAYMENTS COVERAGE CA 99 28 0310 STATED AMOUNT INSURANCE IL 00 03 0908 CALCULATION OF PREMIUM IL 00 17 1198 COMMON POLICY CONDITIONS IL 02 83 0907 WISCONSIN CHANGES-CANC AND NONRENEWAL ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL INLAND MARINE COVERAGE PART: CM 70 71 0794 COMMERCIAL INLAND MARINE DECLARATIONS CM 71 27A 0792 V.E.S.P. EQUIPMENT COVERAGE IM 78 05 0707 SCHEDULE OF COVERAGES - DIC CL 01 00 0399 COMMON POLICY CONDITIONS CL 01 97 0101 AMENDATORY ENDORSEMENT-WI CL 06 00 0115 CERTIFIED TERRORISM LOSSES CL 07 00 1006 VIRUS OR BACTERIA EXCLUSION CM 00 01 0904 COMMERCIAL IM CONDITIONS CM 01 05 0101 WISCONSIN CHANGES CM 71 28 0116 VOL EMERGENCY SERVICES PORTABLE EQ CM 72 00 0112 LIBERALIZATION AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY IL-7035 (08/93) Policy Number COMMERCIAL POLICY FORMS AND ENDORSEMENT SCHEDULE Policy Effective Date: Schedule Effective Date NOTICE TO POLICYHOLDER:All the forms and endorsements contained in this policy as of the “Schedule Effective Date” are listed above. Forms and endorsements added to the policy after this date will appear on a “Policy Changes” endorse- ment. Please read your policy and all “Policy Changes” carefully. NOTE: All applicable “IL” endorsements will be attached in the Common Section of the policy. S 2212948 APRIL 1, 2018 APRIL 1, 2018 THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL INLAND MARINE COVERAGE PART: IL 00 03 0908 CALCULATION OF PREMIUM IL 00 17 1198 COMMON POLICY CONDITIONS IL 02 83 0907 WISCONSIN CHANGES-CANC AND NONRENEWAL IL 09 52 0115 CAP ON LOSS FROM CERT ACTS OF TERRORISM IL 09 85A 0115 DISCL PURSUANT TO TERR RISK INS ACT IM 21 01 0809 AMENDATORY ENDORSEMENT-WI IM 50 01 0907 SCHEDULE OF EXCL LOCATIONS-DIC IM 78 00 0407 DIC-PROPERTY COVERAGE PART IM 78 06 0407 LOCATION SCHEDULE DIC ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE VESP/ADMINISTRATION COVERAGE PART: VS 70 05 1008 VESP DECLARATIONS IL 00 17 1198 COMMON POLICY CONDITIONS IL 09 85A 0115 DISCL PURSUANT TO TERR RISK INS ACT IL 70 67 0115 WI CHANGES - CANC & NONRENEWAL IL 70 95 0115 WI CHANGES - AMEND OF POLICY COND VS 00 01 1216 VESP MANAGEMENT LIAB COVERAGE FORM VS 02 83 0996 WISCONSIN CHANGES-CANC AND NONRENEWAL VS 70 12 0115 CAP ON LOSSES FROM CERT ACTS OF TERROR VS 80 01 1216 PRIOR AND PENDING LITIGATION EXCLUSION VS 80 02 1216 LIMITED CIVIL LEGAL EXPENSE ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL UMBRELLA COVERAGE PART: CX 00 03A 0199 COMMERCIAL EXCESS/UMBRELLA DEC CXL 4 0403 COMMERCIAL UMBRELLA LIAB COVG CXL 17 1099 ASBESTOS EXCLUSION CXL 34 0403 EMPLOYEE BENEFITS LIAB EXCLUSION CXL 63A 0199 PROPERTY OF OTHERS EXCLUSION CXL 108 0403 INJURY TO VOL FIRE/AMBUL/RES SQ/WKRS LIM CXL 117 0403 VOLUNTEER AMBULANCE & RES SQD LIAB LIM CXL 118 0199 VOL FIRE CO AMBULANCE & RES SQ E & 0 LIM CXL 119 0403 WATERCRAFT LIABILITY LIMITATION CXL 120 0403 CIVIL RIGHTS LIMITATION CXL 127 0199 AMEND OF POLL EXCL & ENERGY OPER LIM FRM CXL 132 0403 PERSONAL & ADVERTISING INJURY LIAB CXL 318 0403 EXCLUSION - LEAD HAZARD CXL 321A 0816 AMENDMENT OF EXPECTED OR INTENDED BI/PD CXL 328 0403 WISCONSIN CHANGES-CANC AND NONRENEWAL CXL 338B 0804 SCHEDULED POLICY FOLLOWING FORM-LIAB COV CXL 383 0702 FUNGI OR BACTERIA EXCLUSION CXL 388 0115 CAP ON LOSSES FROM CERT ACTS OF TERR CXL 400 0403 NUCLEAR ENERGY LIABILITY EXCLUSION END CXL 454 0413 EXCL-FIDUCIARY LIABILITY CXL 462 1115 COMMERCIAL UMBRELLA LIABILITY IL 00 17 1198 COMMON POLICY CONDITIONS IL 09 85A 0115 DISCL PURSUANT TO TERR RISK INS ACT ______________________________________________________________________________________________ THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL CRIME FIDELITY COVERAGE PART: CR 70 26 0292 COMMERCIAL CRIME COVERAGE DECLARATION CR 00 21 0506 COMMERCIAL CRIME COVERAGE FORM AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY IL-7035 (08/93) Policy Number COMMERCIAL POLICY FORMS AND ENDORSEMENT SCHEDULE Policy Effective Date: Schedule Effective Date NOTICE TO POLICYHOLDER:All the forms and endorsements contained in this policy as of the “Schedule Effective Date” are listed above. Forms and endorsements added to the policy after this date will appear on a “Policy Changes” endorse- ment. Please read your policy and all “Policy Changes” carefully. NOTE: All applicable “IL” endorsements will be attached in the Common Section of the policy. S 2212948 APRIL 1, 2018 APRIL 1, 2018 THE FOLLOWING FORMS AND ENDORSEMENTS ARE APPLICABLE TO THE COMMERCIAL CRIME FIDELITY COVERAGE PART: CR 01 06 0702 WISCONSIN CHANGES CR 02 45 0702 WISCONSIN CHANGES CR 70 36 0116 ERISA INFLATION GUARD ENDORSEMENT CR 79 22 0116 EMERGENCY SERVICES CRIME ELITEPAC END IL 00 03 0908 CALCULATION OF PREMIUM IL 00 17 1198 COMMON POLICY CONDITIONS IL 02 83 0907 WISCONSIN CHANGES-CANC AND NONRENEWAL IL 09 35 0702 EXCL OF CERTAIN COMPUTER-RELATED LOEPES SCR 04 08 0917 EMPLOYEE THEFT-NAME OR POSITION SCHEDULE SCR 20 08 0917 CONVERT TO AN AGGREGATE LIMIT OF INS SCR 25 47 0917 U.S.DEPT OF LABOR-ERISA PLAN COVERAGE AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT POLICY NUMBER: IL 09 85 01 15 THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. SCHEDULE SCHEDULE — PART I Terrorism Premium (Certified Acts) This premium is the total Certified Acts premium attributable to the following Coverage Part(s), Coverage Form(s) and/or Policy(ies): Additional information, if any, concerning the terrorism premium: SCHEDULE — PART II Federal share of terrorism losses Year: (Refer to Paragraph B. in this endorsement.) Federal share of terrorism losses Year: (Refer to Paragraph B. in this endorsement.) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule of this endorsement or in the policy Declarations. Copyright, Insurance Services Office, Inc., 2015 IL 09 85 01 15 Page 1 of 2 S 2212948 S 2212948 $680.00 INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART GENERAL LIABILITY COVERAGE PART UMBRELLA LIABILITY COVERAGE PART 82%2018 81%2019 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY B. Disclosure Of Federal Participation In Payment Of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals a percentage (as shown in Part II of the Schedule of this endorsement or in the policy Declarations) of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. C. Cap On Insurer Participation In Payment Of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Copyright, Insurance Services Office, Inc., 2015 IL 09 85 01 15 Page 2 of 2 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2010 Selective Insurance Company of America. All rights reserved. IL 79 90 10 10 Page 1 of 1 THIRD PARTY NOTICE TO DESIGNATED PERSON(S) OR ORGANIZATION(S) POLICY NUMBER: IL 79 90 10 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART BUSINESS AUTO COVERAGE PART COMMERCIAL UMBRELLA LIABILITY COVERAGE PART GARAGE COVERAGE PART BUSINESSOWNERS COVERAGE PART The policy provisions relating to cancellation or non- renewal as provided in the Condition Section or as amended by any applicable state cancellation endorse- ments are modified as follows: If we cancel or non-renew this policy for any reason other than nonpayment of premium or at the request of or on behalf of the Named Insured, we agree that the individual person(s) or organization(s) listed in the Schedule below and the Named Insured will be notified prior to the effective date of cancellation when such notice is required in a written contract. The manner and timing of the notice will be as required by law, or the number of days shown in the Schedule below, whichever is greater. A transfer of this policy from one insurance affiliate to another within the same insurance holding group shall not be deemed a cancellation, unless prohibited by law. If we cancel the policy for nonpayment of premium, the number of days advance notice provided to the person(s) or organization(s) listed in the Schedule below will be as required by law. If notice is mailed, proof of mailing to the address shown in the Schedule below will be sufficient proof of notice. In no event will coverage extend beyond the actual expiration, termination or cancellation of the policy. Nothing in this endorsement shall confer additional insured status on any entity scheduled herein. Name of Person(s) or Organization(s) Mailing Address No. Of Days Notice S 2212948 CITY OF MUSKEGO W182 S8200 RACINE AVENUE 30 MUSKEGO, WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY CERTIFIED TERRORISM LOSS AAIS CL 06 00 01 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ THIS CAREFULLY. 1. The following definitions are added. a. “Certified act of terrorism” means an act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States: 1) To be an act of terrorism; 2) To be a violent act or an act that is dangerous to human life, property, or infrastructure; 3) To have resulted in damage: a) W ithin the United States; or b) To an air carrier (as defined in section 40102 of title 49, United States Code); to a United States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regulation in the United States), regardless of where the loss occurs; or at the premises of any United States mission; 4) To have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion; and 5) To have resulted in insured losses in excess of five million dollars in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act, as amended. b. “Certified terrorism loss” means loss that results from a “certified act of terrorism ”. 2. The “terms” of any terrorism exclusion that is part of or that is attached to this Coverage Part are amended by the following provision: This exclusion does not apply to “certified terrorism loss”. 3. The following provision is added. If the Secretary of the Treasury determines that the aggregate amount of “certified terrorism loss” has exceeded one hundred billion dollars in a calendar year (January 1 through December 31), and “we” have met “our” insurer deductible under the Terrorism Risk Insurance Act, as amended, “we” will not pay for any portion of “certified terrorism loss” that exceeds one hundred billion dollars. If the “certified terrorism loss” exceeds one hundred billion dollars in a calendar year (January 1 through December 31), losses up to one hundred billion dollars are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury under the Terrorism Risk Insurance Act, as amended. 4. The following provisions are added. a. Neither the “terms” of this endorsement nor the “terms” of any other terrorism endorsement attached to this Coverage Part provide cover- age for any loss that would otherwise be excluded by this Coverage Part under: 1) Exclusions that address war, military action, or nuclear hazard; or 2) Any other exclusion; and b. The absence of any other terrorism endorse- ment does not imply coverage for any loss that would otherwise be excluded by this Coverage Part under: 1) Exclusions that address war, military action, or nuclear hazard; or 2) Any other exclusion. Copyright, American Association of Insurance Services, Inc., 2015 CL 06 00 01 15 Page 1 of 1 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number COMMERCIAL PROPERTY COVERAGE DECLARATION Policy Effective Date: Coverage Effective Date: Insurance is provided only for those coverages for which a specific limit is shown in the following coverage schedule C o v e r a g e — S c h e d u l e d L o c a t i o n s Prem. No. Bldg. No. Coverage Limit of Insurance Covered Cause of Loss Coins Deductible Valuation Inflation Guard Coverage — Blanket Locations Prem. Bldg. Coverage Rating Covered Cause Coins Deductible Valuation Inflation Blanket No. No. Value of Loss Guard ID # Business Income Prem. No. Bldg. No. Coverage Type Limit of Insurance BI Waiting Period (hrs) Coins Monthly Limit of Indemnity Max Period of Indemnity Extended Period of Indemnity Blanket ID # Blanket Coverage Blanket ID # Blanket Group Total Blanket Limit Extra Expense Prem. No. Bldg. No. Limit of Insurance Monthly Limitation Prem. No. Bldg. No. Limit Monthly Limitation Forms and Endorsements: Refer to “Commercial Policy Forms and Endorsement Schedule” Premium Amount (This premium may be subject to adjustment) CP-7026 (06/17) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 $6,494.00 001 001 BUILDING $2,461,000 SPECIAL 90%$1,000 RC 1 002 001 BUILDING $2,019,500 SPECIAL 90%$1,000 RC 1 003 001 BUILDING $2,361,000 SPECIAL 90%$1,000 RC 1 004 001 BUILDING $1,585,000 SPECIAL 90%$1,000 RC 1 001 001 BPP INCL STOCK $117,000 SPECIAL 90%$1,000 RC 2 002 001 BPP INCL STOCK $117,000 SPECIAL 90%$1,000 RC 2 003 001 BPP INCL STOCK $117,000 SPECIAL 90%$1,000 RC 2 004 001 BPP INCL STOCK $117,000 SPECIAL 90%$1,000 RC 2 001 001 PERS PROP OTHERS $10,000 SPECIAL 90%$1,000 RC 2 CONTINUED ON SCHEDULE: CP-7027 1 1 BI INCLUDING RV ACTUAL LOSS 72 2 1 BI INCLUDING RV ACTUAL LOSS 72 3 1 BI INCLUDING RV ACTUAL LOSS 72 4 1 BI INCLUDING RV ACTUAL LOSS 72 BLANKET GROUP 1 FOR BUILDING ONLY $8,426,500 BLANKET GROUP 2 FOR BUSINESS PERSONAL PROP ONLY $508,000 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number COMMERCIAL PROPERTY MORTGAGE HOLDERS SCHEDULE Policy Effective Date: Schedule Effective Date: Prem. No. Bldg. No. Mortgage Holder Name and Address CP-7623 (10/11) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, ISO Properties, Inc., 2006 CP 15 32 06 07 CIVIL AUTHORITY CHANGE(S) POLICY NUMBER: COMMERCIAL PROPERTY CP 15 32 06 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS INCOME (AND EXTRA EXPENSE) COVERAGE FORM BUSINESS INCOME (WITHOUT EXTRA EXPENSE) COVERAGE FORM EXTRA EXPENSE COVERAGE FORM SCHEDULE Premises Number Building Number Schedule Part A Coverage Period (Number Of Days) Schedule Part B Radius (Number Of Miles) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage Period Under the Additional Coverage — Civil Authority, the four-week coverage period is replaced by the number of days indicated in Part A of the Schedule, subject to all other provisions of that Additional Coverage. If there is no entry in Part A of the Schedule, the four-week coverage period continues to apply, subject to all other provisions of the Additional Coverage — Civil Author- ity. B. Radius The Additional Coverage — Civil Authority in- cludes a requirement that the described premises are not more than one mile from the damaged property. Such one-mile radius is replaced by the number of miles indicated in Part B of the Schedule, subject to all other provisions of that Additional Coverage. If there is no entry in Part B of the Schedule, the one-mile radius continues to apply, subject to all other provisions of the Addi- tional Coverage — Civil Authority. C. The coverage provided under this endorsement does not increase the applicable Limit of Insur- ance. S 2212948 ALL ALL 5 MILES AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2011 Selective Insurance Company of America. All rights reserved. CP 76 11 10 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 4 GREENPAC® ENHANCEMENT ENDORSEMENT POLICY NUMBER: COMMERICAL PROPERTY CP 76 11 10 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance under the following: BUILDING AND PERSONAL PROPERTY COVERAGE FORM CONDOMINIUM ASSOCIATION COVERAGE FORM CONDOMINIUM COMMERCIAL UNIT-OWNERS COVERAGE FORM BUSINESS INCOME (AND EXTRA EXPENSE) COVERAGE FORM BUSINESS INCOME (WITHOUT EXTRA EXPENSE) COVERAGE FORM EXTRA EXPENSE COVERAGE FORM SCHEDULE GREEN PROPERTY - INCREASED COSTS Any One Loss Occurrence Any One Policy Period GREEN SOFT COSTS Any One Loss Occurrence Any One Policy Period Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Coverage provided by this endorsement applies when there has been direct physical loss or damage to covered property listed in the Declarations or Supplemental Declarations from a covered cause of loss. A. GREEN PROPERTY — INCREASED COSTS The following is added under Additional Coverages in the Building and Business Personal Property, Condo- minium Association and Condominium Commercial Unit-Owners Coverage Forms: 1. Building — Increased Cost a. We will pay the reasonable increased costs to repair or replace the damaged or destroyed portion or parts of the building with “green“ property meeting the standards of a “green standards organization“ provided it performs the same or similar function and is otherwise of like kind and quality. b. We will pay the reasonable increased costs to employ methods and processes of construc- tion and debris recycling consistent with those of a “green standards organization“ in the repair and replacement of the damaged or de- stroyed building. Any payments you receive for the recycled debris shall be deducted from the amount of the loss. c. We will not pay under this Additional Coverage: i. Until the property is actually repaired or replaced, at the same, or another, premises; and ii. Unless the repairs or replacement are made as soon as reasonably possible after the loss or damage, not to ex- ceed two years. We may extend this period in writing during the next two years. d. This Additional Coverage does not apply to: i. Buildings insured on other than a Replacement Cost basis; or ii. Vacant buildings in accordance with the meaning of Vacancy in E.6. under LOSS CONDITIONS. S 2212948 $25,000 $25,000 $25,000 $25,000 AGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPY Copyright, 2011 Selective Insurance Company of America. All rights reserved. CP 76 11 10 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 4 2. Tenant Improvements and Betterments — Increased Cost a. We will pay the reasonable increased costs to repair or replace the damaged or destroyed portion of your use interest as tenant in improvements and betterments with “green“ property that meets the standards of a “green standards organization“ provided it performs the same or similar function and is otherwise of like kind and quality. b. We will pay the reasonable increased costs to employ methods and processes of construc- tion and debris recycling consistent with those of a “green standards organization“ in the repair and replacement of the your use interest in damaged or destroyed tenant improvements and betterments. Any payments you receive for the recycled debris shall be deducted from the amount of the loss. c. We will not pay under this Additional Cover- age: i. Until the property is actually repaired or replaced, at the same, or another, prem- ises; and ii. Unless the repairs or replacement are made as soon as reasonably possible after the loss or damage, not to exceed two years. We may extend this period in writing during the next two years. d. This Additional Coverage does not apply to tenant improvements and betterments at locations: i. Insured on other than a Replacement Cost Basis; or ii. In Vacant Buildings in accordance with the meaning of Vacancy LOSS CONDITIONS. 3. Business Personal Property (other than Tenant Improvements and Betterments) — Increased Cost a. We will pay reasonable increased costs to replace or repair lost or damaged business personal property other than your use interest in tenant improvements and betterments with “green“ property that meets the standards of a “green standards organization“ provided it performs the same or similar function and it is otherwise of like kind and quality. b. We will pay the reasonable increased costs to employ methods and processes of construction and debris recycling con- sistent with those of a “green standards organization“ in the repair and replace- ment of the damaged or destroyed business personal property. Any pay- ments you receive for the recycled debris shall be deducted from the amount of the loss. c. We will not pay under this Additional Coverage: i. Until the property is actually repaired or replaced, at the same, or another, premises; and ii. Unless the repairs or replacement are made as soon as reasonably possible after the loss or damage, not to exceed two years. We may extend this period in writing during the next two years. d. This Additional Coverage does not apply to: i. “Stock“; ii. Personal Property Of Others; or iii. Business personal property insured on other than a replacement cost basis. 4. Limits of Insurance A. Subject to the provisions in Paragraphs A.1. through 3. above, the most we will pay for loss or damage in any one oc- currence is the lesser of: (1) The limit of insurance in the Schedule applicable to this endorsement; (2) With respect to buildings (A.1. above) and tenant improvements and better- ments (A.2. above): i. The additional cost for replace- ment of lost or damaged property with “green“ property and the recycling of debris consistent with “basic green standards“ of a “green standards organization“; or ii. The additional cost for replace- ment of lost or damaged property with “green“ property or the recycling of debris consistent with the same standards level of the “green standards organization“ if the building or commercial interior has already met that higher level. This applies whether the building or commercial interior was certi- fied at the time of the loss or not; AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2011 Selective Insurance Company of America. All rights reserved. CP 76 11 10 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 4 (3) With respect to Business Personal Prop- erty Other than Tenant Improvements and Betterments (A.3. above), the additional cost for replacement of lost or damaged property with “green“ property and the recycling of debris consistent with “basic green standards“ of a “green standards organization“; or (4) Up to 15% of the amount that would have been paid had this endorsement not been included with the policy; B. Subject to the provisions of Paragraph A. above in this Section: (1) The limit in any one loss occurrence for Green Property Increased Cost is the most we will pay under this endorsement re- gardless of the number of covered buildings or locations; (2) The limit in any one policy period for Green Property Increased Cost is the most we will pay for all covered losses under this endorsement in any one policy period regardless of the number of covered buildings, locations or losses. (3) The limits of insurance provided by Green Property — Increased Cost are in addition to the Limits of Insurance shown in the declarations. B. GREEN SOFT COSTS The following is added under Additional Coverages in the Building and Business Personal Property, Condo- minium Association and Condominium Commercial Unit-Owners Coverage Forms: The coverages listed in this SECTION B. apply follow- ing total loss or damage to buildings or tenant improve- ments and betterments. However, if the buildings or tenant improvements and betterments were previously constructed in accordance with the standards of a “green standards organization“, the coverages in SECTION B. apply to all losses. 1. LEED Accredited Green Design Professionals We will pay reasonable additional costs for the fees of architects or engineers granted LEED accreditation by the United States Green Building Council. 2. Recertification or Certification a. If the building or commercial interior was certified by a “green standards organiza- tion“ prior to the loss, we will pay the additional reasonable and necessary fees for recertification with the same “green standards organization“ for the same level of certification that existed prior to the loss. b. If the building or commercial interior was not certified by a “green standards organi- zation“ prior to the loss, we will pay the reasonable and necessary costs to certify it for “basic green standards“ level. 3. Testing of Building Systems We will pay the necessary and reasonable expenses to test building systems and build- ing equipment to determine whether or not they are functioning in accordance with the planned specifications. We will not pay expenses to test production equipment used in your business. 4. Ventilation We will pay for the reasonable and necessary costs you incur to flush out or ventilate the air in the repaired, replacement or reconstructed building or commercial interior in accordance with the applicable standards of the “green standards organization“. 5. Limit of Insurance a. Subject to the provisions in Paragraphs A.1. through 4. above, the most we will pay for Green Soft Costs is the limit of insurance in the Schedule applicable to Green Soft Costs. b. The limit in any one loss occurrence is the most we will pay under this endorsement for Green Soft Costs regardless of the number of covered buildings or locations. c. The limit in any one policy period is the most we will pay under this endorsement for Green Soft Costs in any one policy period regardless of the number of covered buildings, locations or losses. d. The limit of insurance provided by Green Soft Costs is in addition to the Limits of Insurance shown in the declarations. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2011 Selective Insurance Company of America. All rights reserved. CP 76 11 10 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 4 C. GREEN INCREASED PERIOD OF RESTORATION The following is added under Additional Coverages in the Business Income (and Extra Expense) Coverage Form and the Business Income (without Extra Expense) Coverage Form, or the Extra Expense Coverage Form. 1. The “period of restoration“ is extended to include the increased period of time required to repair, replace or reconstruct lost or damaged building, improvements and betterments or business per- sonal property using products, materials, design and construction methods covered by the provi- sions in SECTION A. of this endorsement. 2. This coverage applies for up to 30 days beyond the “period of restoration“ that would have otherwise occurred. 3. Coverage included in this Section is included in and does not increase the limit or limits of insurance applicable to Business Income and/or Extra Expense shown in the Declarations. D. EXCESS ORDINANCE OR LAW COVERAGE 1. The coverage provided by this endorsement shall apply in excess of any coverage provided in this policy elsewhere for Ordinance or Law covering the repair, replacement or reconstruction of prop- erty to the standards of a “green standards organization“ or for other environmentally friendly or sustainable design features mandated by the applicable building code. 2. The coverage provided in this SECTION D. applies to the Increased Cost of Construction part of Ordinance or Law Coverage. It does not apply to any costs to demolish property or for loss to undamaged property. 3. The coverage provided in this SECTION D. does not apply to additional costs for use of “green“ construction materials or construction methods or processes or payment of professionals fees or other expenses covered under SECTION C. broader in scope than that provided in SECTIONS A. or B. of this endorsement. 4. The coverage provided in this SECTION D. does not apply to any costs due to an Ordinance or Law that you were required but failed to comply with before the loss. E. ADDITIONAL EXCLUSIONS 1. The coverages provided by this endorsement do not apply to the following: a. Newly acquired property; b. Property at locations not specified; or c. Property at unnamed locations. 2. The coverages provided by this endorsement do not apply to any increased loss payment: a. To clean up or remove “pollutants“; b. To clean up, remove, restore or replace property because of the presence of “fungus“, wet or dry rot or bacteria; or c. Attributable to any standards you did not comply with before the loss. Paragraph 2.b. does not apply in New York. F. Definitions The following definitions are added: 1. “Green“ means: building materials, compo- nents, products, equipment; and construction and design methods and technologies which reduce environmental impact through con- servation of energy, water and other natural resources. This includes creation of less toxic and cleaner buildings and surrounding envi- ronments. 2. “Green Standards Organization“ means a recognized authority on “green“ including: a. The United States Green Building Council (USGBC) with its Leadership in Energy and Environmental Development (LEED® grading system); b. The Green Building Initiative with its Green Globes® assessment and rating system; c. The United States Department of Energy and Environmental Protection Agency’s “Energy Star®“ requirements; and d. Other building site use and development, water saving, energy efficiency, materials, equipment, appliances or other environ- mental quality designed and maintained standards. 2. “Basic Green Standards“ means the first level or least rigorous level of the grading or evaluation systems applied to a building, structure, or commercial interior by a “green standards organization“. G. Amended Condition — Coinsurance The Coinsurance condition does not apply to the coverage provided in this endorsement. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 6 CRISIS RESPONSE COVERAGE POLICY NUMBER: COMMERCIAL PROPERTY CP 76 13 05 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL PROPERTY COVERAGE PART SCHEDULE CRISIS INCIDENT BUSINESS INCOME (AND EXTRA EXPENSE) Any One Crisis Incident At Any One Covered Location All Crisis Incidents At Any One Covered Location In Any One Policy Period CRISIS INCIDENT COUNSELING EXPENSE Any One Crisis Incident At Any One Covered Location All Crisis Incidents At Any One Covered Location In Any One Policy Period Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. CRISIS INCIDENT BUSINESS INCOME (AND EXTRA EXPENSE) 1. Crisis Incident Business Income a. We will pay for the actual loss of “crisis incident business income” you sustain due to the necessary “suspension” of your “opera- tions” during the “crisis incident period of restoration”. The “suspension” must be caused by a “covered crisis incident” at a “covered location”. Coverage applies to loss sustained at the “covered location” where the “covered crisis incident” occurred. b. If the necessary “suspension” of your “opera- tions” caused by or resulting from the “covered crisis incident” produces a “crisis incident busi- ness income” loss payable under this policy, we will pay for the actual loss of business income you sustain during the policy period that: (1) Begins on the date “operations” are resumed or tenability of the covered loca- tion is returned to its pre-loss level; and (2) Ends on the earlier of: (a) The date you could restore your “operations” with reasonable speed, to the level that would generate business income com- parable to the level that would have existed had no “covered crisis incident” occurred; or (b) The date you could have restored the covered premises with rea- sonable speed to a level that would have generated the rental income that would have existed if the “covered crisis incident” had not occurred; or (c) Thirty (30) consecutive days after the date determined in (2)(a) above. c. Coverage will begin after a twenty-four (24) hour Waiting Period and end the earlier of the date your “operations” is restored to its pre-loss condition; or sixty (60) consecutive days after the “covered crisis incident”. S 2212948 $25,000 $25,000 $10,000 $10,000 AGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 6 2. Crisis Incident Extra Expense a. We will pay “Crisis Incident Extra Expense” (other than the expense to repair or replace property) you incur during the “crisis incident period of restoration” caused by or resulting from a “covered crisis incident” to: (1) Avoid or minimize the “suspension” of business and to continue operations at the “covered location” or at replacement or temporary location, including relocation expenses and costs to equip and operate the replacement location or temporary location; or (2) Minimize the “suspension” of business if you cannot continue “operations”. Coverage applies to expenses incurred at the “covered location” where the “covered crisis incident” occurred. b. This coverage will end the earlier of: (1) The date your “operations” is restored to a condition similar to that which would have existed had there been no “covered crisis incident”; or (2) Sixty (60) consecutive days after the “covered crisis incident”. c. We will not pay for the following under “Crisis Incident Extra Expense”: (1) The base salary of employees responsible for public relations or communications functions for you; (2) Retainers or other on-going contracted fees from a Public Relations or Commu- nications Organization in effect at the time of the “covered crisis incident”; (3) Ransom payments; or (4) Fines or penalties. d. No deductible applies to “Crisis Incident Extra Expense”. e. Limits for Crisis Incident Business Income (And Extra Expense) The most we will pay for loss: (1) In any one “covered crisis incident” at any one “covered location”; and (2) In any one policy year for All Crisis Incidents at any one “covered location”, is the applicable Limit of insurance in the Schedule. If loss payment on the first occurrence does not exhaust this amount, then the balance is available for subsequent loss sustained during the policy period. With respect to an incident which begins in one policy period and contin- ues or results in additional loss in subsequent policy period(s), all loss is deemed to be sustained in the policy period in which it occurs. B. OFF-PREMISES CRISIS INCIDENT EXTRA EXPENSE 1. We will pay “Off-Premises Crisis Incident Extra Expense” you incur because of “covered crisis incidents” away from the “covered location” for up to (60) consecu- tive days after the “covered crisis incident”. 2. The most we will pay for ”Off-Premises Crisis Incident Extra Expense” in any one policy year is $15,000, regardless of the number of “covered crisis incidents” or “covered locations”. This limit is in addi- tion to the Limits of Insurance shown the in the Schedule of this endorsement. 3. We will not pay for the following under “Off-Premises Crisis Incident Extra Ex- pense”: a. The base salary of your employees responsible for public relations or communications functions; b. Retainers or other on-going con- tracted fees from a Public Relations or Communications Organization in effect at the time of the “Covered Crisis Incident”; c. Ransom payments; or d. Fines or penalties. 4. No deductible applies to “Off-Premises Crisis Incident Extra Expense”. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 6 C. CRISIS INCIDENT COUNSELING EXPENSE 1. We will pay reasonable and necessary expenses incurred by you for group crisis counseling services you provide following a “covered crisis incident” at a “covered location”. Coverage applies to ex- penses incurred at the “covered location” where the “covered crisis incident” occurred. Expense payments apply for up to sixty (60) days from the date the “covered crisis incident” occurs. We will not pay for expenses occurring after this sixty (60) day period, even if they are related to other expenses which began during the sixty (60) day coverage period. 2. Crisis Incident Counseling Expense does not apply to loss caused by or resulting from food contami- nation shutdown. 3. Coverage does not apply to individuals who participated in or were responsible for the “covered crisis incident.” 4. The most we will pay under Crisis Incident Counseling Expense: a. In any one “covered crisis incident” at any one “covered location” is the Crisis Incident Counseling Expense Any One Crisis Incident At Any One Covered Location limit in the Schedule; and b. For all expenses for “covered crisis incidents” in any one policy period is the Crisis Incident Counseling Expense All Crisis Incidents Any One Policy Period limit in the Schedule. 5. No deductible applies to this coverage. D. CONDITIONS 1. The Other Insurance Condition is replaced by the following: a. Other Insurance (1) If the loss is also covered elsewhere under this policy or in a separate policy, we will pay only for the amount of the loss in excess of the amount due from the other insurance, whether collectible or not. (2) If the other insurance coverage has a higher deductible, we will pay for the differ- ence between the deductible applicable to the coverage in this endorsement and the deductible applicable to the other cover- age. (3) With respect to Crisis Incident Coun- seling Expense, other insurance in- cludes insurance coverage or non- insurance services from an Employee Assistance Plan or similar service for mental health counseling or crisis intervention for your employees. E. LOSS CONDITIONS The following conditions apply in addition to the Common Policy Conditions and the Commercial Property Conditions. 1. Appraisal If we and you disagree on the amount of the Net Income and operating expense or the amount of loss, either may make a written demand for an appraisal of the loss. In this event, each party will select a competent and impartial appraiser. The two appraisers will select an umpire. If they cannot agree, either may request the selection be made by a judge of a court having jurisdiction. The appraisers will state separately the amount of Net Income and operating expense amount of loss. If they fail to agree, they will submit the difference to the umpire. A decision agreed to by any two will be binding. Each party will: a. Pay its chosen appraiser; and b. Bear the other expenses of the appraisal and umpire equally. If there is an appraisal, we will still retain our right to deny the claim. 2. Duties In The Event Of Loss In the event of a “covered crisis incident” you must: a. Notify law enforcement if a law may have been broken. b. Notify us as soon as practicable that a “covered crisis incident” has taken place or that another incident or incidents possi- bly leading to a “covered crisis incident” or “covered crisis incidents” has or have taken place. c. Upon our request, submit written noti- fication if the initial notification was made verbally. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 6 d. Include the following in the notice: (1) The how, when and where of the “covered crisis incident”; (2) Names, addresses and other pertinent information pertaining to injured persons or witnesses; and (3) The nature and location of injuries and damages arising out of the “covered crisis incident”. e. Notify us as soon as practicable if you intend to provide crisis counseling services. f. Take all reasonable steps to protect the “covered location” from further loss or damage and the individuals from further injury. These steps will not increase the limits of insurance, but will be included for consideration in the settlement of the claim. g. As often as may be reasonably required, permit us to inspect the property to prove the injury, damage or loss and to examine your books and records. h. Send us a signed, sworn proof of loss contain- ing the information we request to investigate the claims within sixty (60) days of our request. We will supply you with the necessary forms. i. Cooperate with us in the investigation or settlement of the claim. j. If you intend to continue your business, you must resume all or part of your “operations” as quickly as possible. 3. We may examine any insured under oath, while not in the presence of any other insured and at such times as may be reasonably required, about any matter relating to this insurance or the claim, including an insured’s books and records. In the event of an examination, an insured’s answers must be signed. F. LOSS DETERMINATION 1. The amount of Crisis Incident Business Income loss will be determined based on: a. The Net Income of the business before the “covered crisis incident” occurred; b. The likely Net Income of the business if no “covered crisis incident” had occurred, but not including any Net Income that would likely have been earned as a result of an increase in the volume of business due to favorable business conditions caused by the impact of the “covered crisis incident” on customers or on other businesses; c. The operating expenses, including payroll expenses, necessary to resume “opera- tions” with the same quality of service that existed just before the “covered crisis incident”; and d. Other relevant sources of information, including: (1) Your financial records and accounting procedures; (2) Bills, invoices and other vouchers; and (3) Deeds, liens or contracts. 2. The amount of Crisis Incident Extra Expense will be determined based on: a. All expenses, including “crisis incident communications expenses”, that exceed the normal operating expenses that would have been incurred by “operations” during the “period of restoration” if the “covered crisis incident” had not occurred. We will deduct from the total of such expenses: (1) The salvage value that remains of any property bought for temporary use during the “crisis incident period of restoration”, once “operations“ are resumed; and (2) Any Extra Expense that is paid for by other insurance, except for insurance that is written subject to the same plan, terms, conditions and provisions as this insurance; and b. Necessary expenses that reduce the Business Income loss that otherwise would have been incurred. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 6 3. Resumption Of Operations We will reduce the amount of your: a. Crisis Incident Business Income Loss, other than Crisis Incident Extra Expense, to the extent you can resume your normal “opera- tions”, in whole or in part at the described premises or elsewhere. b. Crisis Incident Extra Expense loss to the extent you can return “operations” to normal and discontinue such Crisis Incident Extra Expense. 4. If you do not resume “operations”, or do not resume “operations” as quickly as possible, we will pay based on the length of time it would have taken to resume “operations” as quickly as possible. G. DEFINITIONS 1. “Communicable disease” means bacterial micro organism transmitted through human contact to food. 2. “Covered crisis incident” means. a. Violent Act. A physical act or attempted act done with malice and intent to cause injury or death to person or persons. This excludes acts committed, threatened or attempted by you, or any of your partners, directors, officers or trustees. b. The following threatened, attempted or com- mitted acts: (1) Abduction or kidnapping. The wrongful and illegal seizure of a person. This does not apply to abduction or kidnapping of the person by a parent, spouse, other relative, boyfriend, girlfriend or life partner. (2) Stalking of employees or customers; (3) Sexual assault; or (4) Use of a firearm. This excludes acts committed, threatened or attempted by you, or any of your partners, directors, managers (if you are a limited liability company), officers or trustees. c. Food Contamination Shutdown or the shutdown of a business or location by the Board of Health or other governmental body because of the discovery of, or suspicion of, “food contamination”. 3. “Covered location” means any location or premises you own or occupy, including the area within 1,000 feet of the building at which these are located, where building or business personal property is insured under this policy. However, a location or premises with more than one building or business personal prop- erty in more than one building is considered one “covered location” with respect to the coverages provided by this endorsement, even if the distance between buildings is less than 1,000 feet. 4. “Crisis Incident Business Income” means the: a. Net income (net profit or loss before income taxes) that would have been earned or incurred; and b. Continuing normal operating expenses incurred, including payroll. For manufacturing risks, this includes the net sales value of production. For all risks, this includes “rental value”. 5. “Crisis Incident Communication Expense” means: a. Reasonable and necessary expenses for the services of a Public Relations or Other Crisis Communications Firm to guide, advise or assist you in internal and external crisis communications; and b. Reasonable and necessary expenses incurred by your own Communications Department beyond those of its normal communications activities for you to guide, advise or assist you in internal and external crisis communications. 6. “Crisis Incident Extra Expense” means nec- essary expenses, including “Crisis Incident Communication Expense” you incur during the “crisis incident period of restoration” that you would not have incurred if there had there been no loss at your “covered premises” resulting from a “covered crisis incident”. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2013 Selective Insurance Company of America. All rights reserved. CP 76 13 05 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 6 7. “Crisis incident period of restoration” means the period that begins after the Waiting Period Deductible and ends on the earlier of: a. The date when business is resumed or the “covered location” can be reoccupied by a tenant; or b. Sixty (60) consecutive days after the “covered crisis incident” occurred. 8. “Food contamination” means the occurrence of food poisoning, or suspected food poisoning, of one or more of your patrons resulting from tainted food purchased by you or “communicable disease” transmitted by one or more of your employees. 9. “Off-Premises Crisis Incident Extra Expense” means necessary extra expense such as the additional cost of lodging, food, transportation and “Crisis Incident Communication Expense” you incur as a result of a “covered crisis incident” away from a “covered location”. 10. “Operations” means: a. Your business activities occurring at the described premises; and b. The tenantability of the “covered location”, if you receive rental income from the “covered location”. 11. “Suspension” means: a. The slowdown or cessation of your busi- ness activities; or b. That a part or all of the “covered location” is rendered untenantable, if you receive rental income from the “covered location”. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY SCHEDULE OF COVERAGES DIFFERENCE IN CONDITIONS POLICY NUMBER: AAIS IM 78 05 07 07 (The entries required to complete this schedule will be shown below or on the “schedule of coverages”.) COVERAGES (check one) Blanket Coverage Scheduled Locations Coverage (check one) Refer to Locations Schedule Schedule On File TYPE OF COVERAGES (check one) DIC Coverage DIC Coverage Excluding Property Perils Property Policy Information Insurer Policy Number Excess Coverage (check if applicable) Excess coverage for earthquake Excess coverage for “flood” National Flood Insurance Program (if applicable) Policy Number EARTHQUAKE LIMITS If Income Coverage is part of this policy and a loss is caused by or results from an earthquake, the “limit” for Income Coverage is part of and not in addition to the Earthquake Limits indicated below. Occurrence Limit — The earthquake “occurrence limit” is: Aggregate Limit — The earthquake “aggregate limit” is: Catastrophe Limit — The earthquake “catastrophe limit” is: FLOOD LIMITS If Income Coverage is part of this policy and a loss is caused by or results from a “flood”, the “limit” for Income Coverage is part of and not in addition to the Flood Limits indicated below. Occurrence Limit — The “flood” “occurrence limit” is: Aggregate Limit — The “flood” “aggregate limit” is: Catastrophe Limit — The “flood” “catastrophe limit” is: Copyright, American Association of Insurance Services, Inc., 2007 IM 78 05 07 07 Page 1 of 3 S 2212948 X X X SELECTIVE INSURANCE COMPANY OF AMERICA S 2212948 NOT APPLICABLE $2,588,000 $2,588,000 $2,588,000 $2,588,000 $2,588,000 $2,588,000 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY ALL OTHER COVERED PERILS LIMITS (Excluding Earthquake And Flood) Occurrence Limit — The “occurrence limit” for all other covered perils (excluding earthquake and “flood”) is: Aggregate Limit — The “aggregate limit” for all other covered perils (excluding earthquake and “flood”) is: Catastrophe Limit — The “catastrophe limit” for all other perils (excluding earthquake and “flood”) is: COVERAGE EXTENSIONS LIMIT Additional Debris Removal Expenses Emergency Removal Limited Fungus Coverage SUPPLEMENTAL COVERAGES LIMIT Foundations Of Buildings, Pilings And Underground Pipes Newly Acquired Buildings Ordinance or Law (Undamaged Parts Of A Building) Ordinance or Law (Increased Cost To Repair and Cost To Demolish/Clear Site) Personal Property — Acquired Locations Pollutant Cleanup And Removal Property In Transit COVERAGE OPTION Masonry Veneer (check one) Covered For Loss Caused By Earthquake Not Covered For Loss Caused By Earthquake Copyright, American Association of Insurance Services, Inc., 2007 IM 78 05 07 07 Page 2 of 3 VALUATION (check one) Actual Cash Value Replacement Cost NOT COVERED NOT COVERED NOT COVERED $10,000 30 DAYS $15,000 $100,000 $100,000 COVERED $100,000 $100,000 $25,000 $50,000 X X AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY DEDUCTIBLES Earthquake Deductible Flood Deductible All Other Covered Perils Deductible INCOME COVERAGE PART Coverage Options (check one) No coverage Earnings/”Rents”/Extra Expense Earnings/Extra Expense Income Coverage Limit The Earthquake Limits and Flood Limits are the only “limits” that apply when a covered loss is caused by or results from earthquake or “flood”. Income Coverage Waiting Period OPTIONAL COVERAGES AND ENDORSEMENTS Copyright, American Association of Insurance Services, Inc., 2007 IM 78 05 07 07 Page 3 of 3 $1,000 $1,000 NOT APPLICABLE X NOT COVERED NOT APPLICABLE AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY CG-7035 (06/90) Previous Policy Number Policy Number COMMERCIAL LIABILITY COVERAGE DECLARATION Policy Effective Date:Coverage Effective Date: Business of Named Insured: Insurance is provided only for those coverages for which a specific limit is shown in the following coverage schedule. C o v e r a g e L i m i t s C o m m e r c i a l L i a b i l i t y P r e m i u m ( s ) Rates Advanced Premium Classification Class Code Premium Basis Premises - Operations Products - Completed Operations Premises - Operations Products - Completed Operations Minimum Premium Total Premium Location of all premises you own, rent, or control: Refer to “Schedule of Locations” P r e m i u m a n d R a t e L e g e n d This Schedule lists all your premises, operations and other exposures, as they exist as of the coverage effective date. Forms and Endorsements: Refer to “Commercial Policy Formsand Endorsement Schedule” Total Advance Premium (This premium may be subject to adjustment.) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 VFD COMMERCIAL GENERAL LIABILITY General Aggregate Limit (Other Than Products-Completed Operations) $10,000,000 Products-Completed Operations -- Aggregate Limit $10,000,000 Personal and Advertising -- Injury Limit $4,000,000 Each Occurrence Limit $4,000,000 Damage To Premises Rented To You Limit -- Any One Premises $1,000,000 Medical Expense Limit -- Any One Person $5,000 EMERGENCY SERVICES AND $98.00 GOVERNMENTAL GENERAL LIABILITY EXTENSION COVERAGE TERRORISM $69.00 DATA COMPROMISE 39176 FLAT CHARGE $333.00 ---- Designated Person/Org 31081 35.000 $35.00 LOCATION #001 BUILDING #001 ----------------------------- BOATS RESCUE BOATS SL 20017 1 (T09) 15.921 INCL. $16.00 INCL. (T-503) AMBULANCE SERVICE NOT FOR 40032 41 (T04) 15.425 INCL. $632.00 INCL. PROFIT ONLY (T-503) FIRE DEPARTMENTS VOLUNTEER 43551 13,650 (A) 20.555 INCL. $281.00 INCL. (T-503) LOCATION #002 BUILDING #001 ----------------------------- FIRE DEPARTMENTS VOLUNTEER 43551 9,253 (A) 20.555 INCL. $190.00 INCL. (T-503) LOCATION #003 BUILDING #001 ----------------------------- FIRE DEPARTMENTS VOLUNTEER 43551 11,800 (A) 20.555 INCL. $243.00 INCL. (T-503) CONTINUED ON SCHEDULE: CG-7045 $464.00 $.00 $2,045.00 $.00 $2,045.00 (A) Area - rate per 1000 square feet (T09) Boats - rate per boat (T04) Ambulance - rate per attendent AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, ISO Properties, Inc., 2004 CG 20 26 07 04 ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) 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 for “bodily injury”, “property damage” or “personal and advertising injury” caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A.In the performance of your ongoing operations; or B.In connection with your premises owned by or rented to you. S 2212948 CITY OF MUSKEGO W182 S8200 RACINE AVENUE MUSKEGO, WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2008 CG 24 04 05 09 Page 1 of 2 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. S 2212948 CITY OF MUSKEGO W182 S8200 RACINE AVENUE MUSKEGO, WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2008 CG 24 04 05 09 Page 2 of 2 The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of SECTION IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or “your work” done under a contract with that person or organization and included in the “products-completed operations hazard”. This waiver applies only to the person or organization shown in the Schedule above. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY PRIMARY AND NONCONTRIBUTORY — OTHER INSURANCE CONDITION COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Copyright, Insurance Services Office, Inc., 2012 CG 20 01 04 13 Page 1 of 1 INSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPYINSURED'S COPY Copyright, Insurance Services Office, Inc., 1984 CG 24 12 11 85 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Description of Watercraft: Additional Premium: “See Schedule” (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) 1.Exclusion g. of COVERAGE A (Section I) does not apply to any watercraft owned or used by or rented to the insured shown in the Schedule. 2.WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization legally responsible for the use of any such watercraft you own, provided the actual use is with your permission. BOAT S S 2212948 OWNED RESCUE AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2008 CG 25 04 05 09 Page 1 of 2 DESIGNATED LOCATION(S) GENERAL AGGREGATE LIMIT POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Location(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by “occur- rences” under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which can be attributed only to operations at a single designated “location” shown in the Schedule above: 1. A separate Designated Location General Aggre- gate Limit applies to each designated “location”, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Location General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of “bodily injury” or “property damage” included in the “products-completed operations hazard”, and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or “suits” brought; or c. Persons or organizations making claims or bringing “suits”. 3. Any payments made under Coverage A for dam- ages or under Coverage C for medical expenses shall reduce the Designated Location General Aggregate Limit for that designated “location”. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Location General Aggregate Limit for any other designated “location” shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Location General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by “occur- rences” under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attributed only to operations at a single designated “location” shown in the Schedule above: 1. Any payments made under Coverage A for dam- ages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-com- pleted Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Designated Location General Aggregate Limit. C. When coverage for liability arising out of the “products-completed operations hazard” is provided, any payments for damages because of “bodily injury” or “property damage” included in the “products-com- pleted operations hazard” will reduce the Products- completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Desig- nated Location General Aggregate Limit. S 2212948 SUBJECT TO THE TERMS AND CONDITIONS OF THIS POLICY, EACH DESIGNATED LOCATION LISTED ON THE SCHEDULE OF LOCATIONS SHOWN ON THE DECLARATION PAGE FOR THIS POLICY. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2008 CG 25 04 05 09 Page 2 of 2 D. For the purposes of this endorsement, the Defini- tions Section is amended by the addition of the following definition: “Location” means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. E. The provisions of SECTION III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY PRODUCT RECALL EXPENSE COVERAGE ENDORSEMENT POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 79 35 07 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE SUB-LIMITS OF INSURANCE: “Product Recall Expense” Per Occurrence: $25,000 Annual Aggregate: $50,000 “Additional Covered Expenses” The “Additional Covered Expenses” Per Occurrence and Annual Aggregate Limit is equal to 50% of the above “Product Recall Expense” Limit. DEDUCTIBLE: N/A COVERAGE IN THIS ENDORSEMENT DOES NOT APPLY TO THESE PRODUCTS: THIS ENDORSEMENT ONLY PROVIDES REIMBURSEMENT TO YOU FOR EXPENSES INCURRED BECAUSE OF A COVERED “PRODUCT RECALL”. THIS ENDORSEMENT DOES NOT PROVIDE ANY LIABILITY COVERAGE OR COVERAGE FOR THE COST OR EXPENSE OF DEFENDING ANY CLAIM OR SUIT. A. The following is added to SECTION I — COVER- AGES: SECTION I —LIMITED PRODUCT RECALL EX- PENSE COVERAGE 1. Insuring Agreement a. We will reimburse you for “Product Recall Expense” and “Additional Covered Ex- penses” incurred by you because of a “product recall” to which this insurance applies. The amount of such reimbursement is limited as described in SECTION III — LIMITS OF INSURANCE. No other obliga- tion or liability to pay sums or perform acts or services is covered. b. This insurance applies to a “product recall” only if the “product recall” is initiated in the “coverage territory” during the policy period because: (1) You determine that the “product recall” is necessary; or (2) An authorized government entity has ordered you to conduct a “product recall”. Includes copyrighted material of ISO Properties, Inc., with its permission. CG 79 35 07 08 Page 1 of 5 S 2212948 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY c. We will reimburse you for “Product Recall Expense” and “Additional Covered Ex- penses” only if: (1) These expenses are incurred within one year of the date the “product recall” was initiated; (2) These expenses are reported to us within one year of the date the expenses were incurred; and (3) The product that is the subject of the “product recall” is not listed in the “COVERAGE IN THIS ENDORSE- MENT DOES NOT APPLY TO THESE PRODUCTS” entry in the SCHEDULE above. d. The initiation of a “product recall” will be deemed to have been made only at the earliest of the following times: (1) When you first announced, in any manner, to the general public, your vendors or to your employees (other than those employees directly involved in making the determination) your deci- sion to conduct or participate in a “product recall”. This applies regardless of whether the determination to conduct a “product recall” is made by you or is requested by a third party; or (2) When you first received, either orally or in writing, notification of an order from an authorized government entity to con- duct a “product recall”. e. “Product Recall Expense” or “Additional Covered Expenses” incurred to recall “your products” which contain the same or substantially similar “defects” will be deemed to have arisen out of the same “product recall”. 2. Exclusions This insurance does not apply to “Product Recall Expense” or “Additional Covered Expenses” arising out of: a. Any “product recall” initiated due to the failure of “your product” to accomplish its intended purpose, including any breach of warranty of fitness, whether written or implied. This exclusion does not apply if such failure has caused or is reasonably expected to cause “bodily injury” or “property damage” to tangible property other than “your product”. b. Any “product recall” initiated due to copy- right, patent, trade secret, trade dress, trade name or trademark infringements, or any other intellectual property laws. c. Any “product recall” initiated due to trans- formation of a chemical nature, deterioration or decomposition of “your product”. This exclusion does not apply if it is caused by: (1) An error in manufacturing, design, or processing; (2) Transportation of “your product”; or (3) “Product tampering”. d. Any “product recall” initiated due to expiration of the designated shelf life of “your product”. e. A “product recall”, initiated because of a “defect” in “your product” known to exist by the Named Insured or the Named Insured’s “executive officers”, prior to the date when this Coverage Part was first issued to you or prior to the time “your product” leaves your control or possession. f. A recall of any specific products for which “bodily injury” or “property damage” is excluded under Coverage A — Bodily Injury And Property Damage Liability by endorsement. g. A recall when “your product” or a component contained within “your product” has been: (1) Banned from the market by an authorized government entity prior to the policy period; or (2) Distributed or sold by you subsequent to any governmental ban. h. The defense of a claim or “suit” against you for liability arising out of a “product recall”. i. Any compensatory damages, fines, pen- alties, punitive or exemplary or other non- compensatory damages imposed upon the insured. j. Any loss, cost or expense due to any: (1) Request, demand, order, statutory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, “pollutants”; or Includes copyrighted material of ISO Properties, Inc., with its permission. CG 79 35 07 08 Page 2 of 5 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY (2) Claim or suit by or on behalf of a gov- ernmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of, “pollutants”. k. Liability assumed by you in any contract or agreement. l. Damages or expenses arising out of the violation of any government regulation. m. Any unauthorized change in “your product” after it leaves your possession or control. This exclusion does not apply to a covered “product recall” due to “product tampering.” n. Redistribution or replacement of “your product” which has been recalled by like products or substitutes. o. Caprice or whim of the insured. p. Recall of “your products” that have no known or suspected defect solely because a known or suspected defect in another of “your products” has been found. q. Willful, dishonest, fraudulent, criminal or malicious acts. B. For the purposes of this endorsement, SECTION III — LIMITS OF INSURANCE is replaced by the following: SECTION III — LIMITS OF INSURANCE 1. The Limits of Insurance shown in the SCHED- ULE are Sub-Limits and the rules below fix the most we will pay regardless of the number of: a. Insureds; b. “Product recalls” initiated; or c. Number of “your products” withdrawn. 2. If there are no amounts shown in the SCHED- ULE, these Sub-Limits will apply: a. “Product Recall Expense”: Per Occurrence $25,000 Annual Aggregate $25,000 b. “Additional Covered Expense”: The Per Occurrence and Annual Aggregate is 50% of the “Product Recall Expense” Per Occur- rence and Annual Aggregate limit. 3. The most we will pay for “Product Recall Ex- pense” during any policy period is the Annual Aggregate Sub-Limit shown on this endorse- ment’s SCHEDULE. 4. The most we will pay for “Additional Covered Expenses” during any policy period is 50% of the “Product Recall Expense” Annual Aggregate Sub-Limit on this endorsement’s SCHEDULE. 5. Deductible Provision a. Deductible We will only pay for the amount of “Product Recall Expense” and “Additional Covered Expenses” which are in excess of the deductible amount, if any, shown in the Schedule of this endorsement. The deducti- ble applies separately to each “product recall”. The Limits of Insurance will not be reduced by the amount of this deductible. We may, or will if required by law, pay all or any part of any deductible amount, if applicable, to effect settlement of any claim or “suit”. Upon notice of our payment of a deductible amount, you shall promptly reimburse us for the part of the deductible amount we paid. The Limits of Insurance apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Dec- larations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. C. For the purposes of this endorsement, the Duties In The Event Of Occurrence, Claim Or Suit Condition under SECTION IV — CONDITIONS is replaced by the following: 2. Duties In The Event Of A “Defect” Or A “Product Recall” a. You must see to it that we are notified as soon as practicable of any actual, suspected or threatened “defect” in “your product”, or any governmental investigation, that may result in a “product recall”. To the extent possible, notice should include: (1) How, when and where the “defect” was discovered; (2) The names and addresses of any injured persons and witnesses; and (3) The nature, location and circumstances of any injury or damage arising out of use or consumption of “your product”. Includes copyrighted material of ISO Properties, Inc., with its permission. CG 79 35 07 08 Page 3 of 5 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY b. If a “product recall” is initiated, you must: (1) Immediately record the specifics of the “product recall” and the date it was initiated; and (2) Notify us as soon as practicable. You must see to it that we receive written notice of the “product recall” as soon as practicable. c. You must promptly take all reasonable steps to mitigate the expenses associated with a “product recall”. Any financial gain or salvage recovery you receive or may be entitled to receive from mitigating the expenses will be deducted from the amount of reimbursement that you will receive for “Product Recall Expense” and “Additional Covered Expenses”. d. You and any others involved insured must: (1) Immediately send us copies of pertinent correspondence received in connection with the “product recall”; (2) Authorize us to obtain records and other information; and (3) Cooperate with us in our investigation of the “product recall”. D. For the purposes of this endorsement, the following condition is added to SECTION IV — CONDITIONS: Concealment Or Fraud We will not provide coverage under SECTION I of this endorsement to you, or any other insured, who at any time: 1. Engaged in fraudulent conduct; or 2. Intentionally concealed or misrepresented a material fact concerning a “product recall” or “Product Recall Expenses” or “Additional Cov- ered Expenses” incurred by you under SECTION I of this endorsement. E. The following definitions are added to SECTION V — DEFINITIONS: 1. “Additional Covered Expenses” includes reim- bursement to the named insured for “customer consequential loss of profit expense”, “cost to replace”, “good faith advertising”. 2. “Customer consequential loss of profit expense” means the loss of financial gain incurred by your direct customers as a consequence of the “product recall” of “your product” or the “product recall” of their product because their product incorporated “your product.” 3. “Cost to replace” means the cost to produce or acquire a like replacement product, including the cost to return “your product” to the purchaser, not to exceed the cost of goods sold. This also includes the cost of unsold finished stock but only if your product cannot be repaired, recondi- tioned, decontaminated or made marketable. 4. “Good faith advertising” means those advertising costs you pay for the specific purpose of regaining customer approval or faith in “your product.” 5. “Defect” means a defect, deficiency or inadequacy that creates a dangerous condition. 6. “Product tampering” is an act of intentional alteration of “your product” which has caused or is reasonably expected to cause “bodily injury” or physical injury to tangible property other than “your product”. When “product tampering” is known, suspected or threatened, a “product recall” will be limited to those batches of “your product” which are known or suspected to have been tampered with. For the purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMS, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. 7. “Product recall” means the recall or withdrawal: a. From the market; or b. From use by any other person or organi- zation; of “your products”, or products which contain “your products”, because of known or suspected defects in “your product”, or known or suspected “product tampering”, which has caused or is reasonably expected to cause “bodily injury” or physical injury to tangible property other than “your product”. Includes copyrighted material of ISO Properties, Inc., with its permission. CG 79 35 07 08 Page 4 of 5 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY For the purposes of this insurance, elec- tronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMS, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. 8. “Product Recall Expense” means those reason- able expenses, listed below, paid on a reimbursement basis and directly related to a “product recall”: a. Costs of advertising; b. Costs of stationery, envelopes, production of announcements and postage or facsimiles; c. Costs of overtime paid to your regular non- salaried employees and costs incurred by your employees, including costs of trans- portation and accommodations; d. Costs of hiring independent contractors and other temporary employees; e. Costs of transportation, shipping or packag- ing; f. Costs of warehouse or storage space; or g. Costs of proper disposal of “your products”, or products that contain “your products”, that can not be reused, not exceeding your purchase price or your cost to produce the products. h. Inspection and testing of “your products” to determine whether or not they may be subject to a “product recall”. Includes copyrighted material of ISO Properties, Inc., with its permission. CG 79 35 07 08 Page 5 of 5 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number BUSINESS AUTOMOBILE COVERAGE DECLARATION Policy Effective Date:Coverage Effective Date: Business of Named Insured: Item Two - SCHEDULE OF COVERAGES AND COVERED AUTOS. This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos." "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the COVERED AUTO Section of the Business Auto Coverage Form next to the name of the coverage. C o v e r a g e S c h e d u l e Coverages Covered Autos Symbols Limit The Most We Will Pay For Any One Accident or Loss Premium Liability Personal Injury Protection (or First Party Benefits) Added Personal Injury Protection (or Added First Party Benefits) Auto Medical Payments Uninsured Motorists Underinsured Motorists Physical Damage Comprehensive Coverage Physical Damage Specified Causes of Loss Coverage Physical Damage Collision Coverage Physical Damage Towing and Labor Coverage Separately stated in each P.I.P. Endorsement. Separately stated in each P.I.P. Added Endorsement Actual Cash Value or Cost of Repair, whichever is lessminus any applicable deductible shown on the AutoSchedule for Each Covered Auto for all Loss except Fireor Lightning. Actual Cash Value or Cost of Repair, whichever is lessminus $25 deductible for Each Covered Auto for Losscaused by Mischief or Vandalism. Actual Cash Value or Cost of Repair, whichever is lessminus the applicable deductible shown on the AutoSchedule for Each Covered Auto. for Each Disablement of a Private Passenger Auto. A u t o S c h e d u l e Trade Body Type Vehicle Id. No.Size List Purchased by Insured No. Name Year Truck Size (VIN)Class Use / Class /Radius Code Symbol Year N/U Cost Physical Damage Insurance Comprehensive CollisionNo. Terr. Liability Insurance Premium P.I.P or F.P.B. Add. P.I.P. or F.P.B.. Med. Paymts.Ded. Prem. Specified Causes of Loss Ded. Prem. Towing Prem. Totals $ Items Three – Schedule of Covered Autos You Own (see Auto Schedule) – Loss Payees Subject to Loss Payable Clause: Vehicle No.Name and Address of Loss Payee Forms and Endorsements: Refer to "Commercial Policy Forms and Endorsement Schedule" Total Premium (This premium may besubject to adjustment.) CA-7057 (02/92) Med. Paymts. Prem. S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 VFD $11,904.00 1 $1,000,000 CSL $5,538.00 2 $10,000 $786.00 2 $1,000,000 CSL $208.00 2 $1,000,000 CSL $481.00 7,8 $662.00 7,8 $3,141.00 7 $50 $3.00 Hired Auto and Non-Owned Auto Coverage $25.00 Premium for Endorsement $657.00 WI 1 GMC 84 RESCUE UNI 1GUJK34W5EV543168 M 790900 $33,100 WI 2 FORD 85 LOW TILT C 1FDYD80U2FVA35865 M 790900 $248,000 WI 3 PIER 96 PIERCE 4P1CT02U4TA000495 H 790900 $480,000 WI 4 FORD 99 F350 SUPER 1FTSW31F7XEE51211 M 790900 $126,000 WI 5 PETE 00 CONVENTION 2NPNHD8X8YM520638 H 790900 $330,500 WI 6 PIER 02 1000GPM PU 4P1CT02M92A002273 HTT 790900 $480,000 WI 7 FORD 06 E450 SUPER 1FDXE45P76HB13981 H 790900 $173,000 Um & Uim Motorists Premium WI 1 113 183 38 27 500 12 500 18 WI 2 113 183 38 27 500 26 500 88 WI 3 113 183 38 27 500 41 500 167 WI 4 113 183 38 27 500 18 500 47 WI 5 113 183 38 27 500 31 500 116 WI 6 113 183 38 27 500 41 500 167 WI 7 113 183 38 27 500 21 500 63 CONTINUED ON SCHEDULE: CA-7059 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number BUSINESS AUTOMOBILE COVERAGE DECLARATION (Continued) Policy Effective Date: Coverage Effective Date: Item Four – Schedules of Hired or Borrowed Covered Auto Coverage and Premiums. Liability Insurance – Rating Basis, Cost of Hire State Estimated Cost of Hire Rate per Each $100 Minimum Premium P r e m i u m for Each State Cost of Hire Total Premium Cost of hire means the total amount you incur for the hire of “autos” you don’t own (not including “autos” you borrow or rent from your partners, employees or their family members). Cost of hire does not include charges for service performed by motor carriers of property or passengers. Physical Damage Coverage Coverages L i m i t o f I n s u r a n c e Estimated Annual Cost of Hire Rate per Each $100 Annual Cost of Hire P r e m i u m Comprehensive Actual Cash Value, Cost of Repairs or Whichever is Less Minus Ded. for Each Covered Auto For all Loss Except Fire or Lightning. Specified Causes of Loss Actual Cash Value, Cost of Repairs or Whichever is Less Minus $ 25 Ded. for Each Covered Auto For all Loss caused by Mischief or Vandalism Collision Actual Cash Value, Cost of Repairs or Whichever is Less Minus Ded. for Each Covered Auto Total Premium PHYSICAL DAMAGE INSURANCE applies on a direct primary basis and for purposes of the condition entitled OTHER INSURANCE, any covered “auto” you hire or borrow is deemed to be a covered “auto” you own. Item Five – Schedule for Non-Ownership Liability Named Insured’s Business R a t i n g B a s i s N u m b e r P r e m i u m Number of Employees Other than a Social Service Agency Number of Partners Number of Employees Social Service Agency Number of Volunteers Total Premium Item Six – Schedule for Gross Receipts or Mileage Basis – Liability Insurance – Public Auto or Leasing Rental Concerns - R a t e s P r e m i u m s Liability Insurance Auto Medical Payments Liability Insurance Auto Medical Payments Estimated Yearly Total Premiums CA-7058 (02/92) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 WISCONSIN IF ANY 1.809 $48.00 INCL $48.00 50,000 100 IF ANY .130 50,000 500 IF ANY .190 $25.00 100 $116.00 $116.00 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2011 CA 21 03 11 11 Page 1 of 4 WISCONSIN UNINSURED MOTORISTS COVERAGE POLICY NUMBER: COMMERCIAL AUTO CA 21 03 11 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. For a covered “auto” licensed or principally garaged, or “garage operations” conducted, in Wisconsin, this endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the coverage form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Limit Of Insurance: Each “Accident” Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. We will pay all sums the “insured” is legally entitled to recover as compensatory damages from the owner or driver of an “uninsured motor vehicle”. The damages must result from “bodily injury” sustained by the “insured” caused by an “accident”. The owner’s or driver’s liability for these damages must result from the ownership, maintenance or use of the “uninsured motor vehicle”. 2. Any judgment for damages arising out of a “suit” brought without our written consent is not binding on us. B. Who Is An Insured If the Named Insured is designated in the Declara- tions as: 1. An individual, then the following are “insureds”: a. The Named Insured and any “family members”. b. Anyone else “occupying” a covered “auto” or a temporary substitute for a covered “auto”. The covered “auto” must be out of service because of its breakdown, repair, servicing, “loss” or destruction. c. Anyone else “occupying” an “auto” you do not own who is an “insured” for liability under the coverage form, but only at times when that person is an “insured” for liability under the coverage form. d. Anyone for damages he or she is entitled to recover because of “bodily injury” sustained by another “insured”. 2. A partnership, limited liability company, cor- poration or any other form of organization, then the following are “insureds”: a. Anyone “occupying” a covered “auto” or a temporary substitute for a covered “auto”. The covered “auto” must be out of service because of its breakdown, repair, servicing, “loss” or destruction. b. Anyone else “occupying” an “auto” you do not own who is an “insured” for liability under the coverage form, but only at times when that person is an “insured” for liability under the coverage form. c. Anyone for damages he or she is entitled to recover because of “bodily injury” sustained by another “insured”. S 2212948 $1,000,000 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2011 CA 21 03 11 11 Page 2 of 4 C. Exclusions This insurance does not apply to any of the following: 1. Any claim settled without our consent. 2. The direct or indirect benefit of any insurer or self- insurer under any workers’ compensation, disability benefits or similar law. 3. “Bodily injury” sustained by: a. An individual Named Insured while “occupy- ing” or when struck by any vehicle owned by that Named Insured that is not a covered “auto” for Uninsured Motorists Coverage under this coverage form; b. Any “family member” while “occupying” or when struck by any vehicle owned by that “family member” that is not a covered “auto” for Uninsured Motorists Coverage under this coverage form; or c. Any “family member” while “occupying” or when struck by any vehicle owned by the Named Insured that is insured for Uninsured Motorists Coverage on a primary basis under any other coverage form or policy. 4. Anyone using a vehicle without a reasonable belief that the person is entitled to do so. 5. Punitive or exemplary damages. 6. “Bodily injury” arising directly or indirectly out of: a. War, including undeclared or civil war; b. Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any govern- ment, sovereign or other authority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power or action taken by governmental authority in hindering or defending against any of these. D. Limit Of Insurance 1. Regardless of the number of covered “autos”, “insureds”, premiums paid, claims made or vehi- cles involved in the “accident”, the most we will pay for all damages resulting from any one “accident” is the Limit Of Insurance for Uninsured Motorists Coverage shown in the Schedule or Declarations. 2. The Limit of Insurance under this coverage shall be reduced by: a. All sums paid or payable under any workers’ compensation, disability benefits or similar law; and b. All sums paid by or for anyone who is legally responsible, including all sums paid under this coverage form’s Liability Coverage. 3. No one will be entitled to receive duplicate payments for the same elements of “loss” under this coverage form and any Liability Coverage form, Underinsured Motorists Coverage endorse- ment or Uninsured Motorists Coverage endorse- ment. We will not make a duplicate payment under this coverage for any element of “loss” for which payment has been made by or for anyone who is legally responsible. We will not make a duplicate payment to the extent amounts are paid or payable because of “bodily injury” under workers’ compensation, disability benefits or similar law. E. Changes In Conditions The conditions are changed for Uninsured Motorists Coverage as follows: 1. Other Insurance in the Business Auto and Garage Coverage Forms and Other Insurance — Primary And Excess Insurance Provisions in the Truckers and Motor Carrier Coverage Forms are replaced by the following: If there is other applicable insurance available under one or more policies or provisions of coverage: a. The maximum recovery under all coverage forms or policies combined may equal but not exceed the highest applicable limit for any one vehicle under any coverage form or policy providing coverage on either a primary or excess basis. b. Any insurance we provide with respect to a vehicle the Named Insured does not own shall be excess over any other collectible uninsured motorists insurance providing cov- erage on a primary basis. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2011 CA 21 03 11 11 Page 3 of 4 c. If the coverage under this coverage form is provided: (1) On a primary basis, we will pay only our share of the “loss” that must be paid under insurance providing coverage on a primary basis. Our share is the proportion that our limit of liability bears to the total of all applicable limits of liability for cover- age on a primary basis. (2) On an excess basis, we will pay only our share of the “loss” that must be paid under insurance providing coverage on an excess basis. Our share is the proportion that our limit of liability bears to the total of all applicable limits of liability for coverage on an excess basis. 2. Duties In The Event Of Accident, Claim, Suit Or Loss is changed by adding the following: a. Promptly notify the police if a hit-and-run driver is involved; and b. Promptly send us copies of the legal papers if a “suit” is brought. 3. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following: a. We shall be entitled to the right to recover damages from another only after the “insured” has been fully compensated for damages. b. If we make any payment and the “insured” recovers from another party, the “insured” shall hold the proceeds in trust for us and pay us back the amount we have paid only after the “insured” has been fully compensated for damages. 4. The following condition is added: Arbitration a. If we and an “insured” disagree whether the “insured” is legally entitled to recover dam- ages from the owner or driver of an “uninsured motor vehicle” or do not agree as to the amount of damages that are recover- able by that “insured”, then the matter may be arbitrated. However, disputes concerning coverage under this endorsement may not be arbitrated. Both parties must agree to arbitration. If so agreed, each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. Each party will pay the expenses it incurs and bear the expenses of the third arbitrator equally. b. Unless both parties agree otherwise, arbitra- tion will take place in the county in which the “insured” lives. Local rules of law as to arbitration procedure and evidence will apply. A decision agreed to by two of the arbitrators will be binding. F. Additional Definitions As used in this endorsement: 1. “Family member” means a person related to an individual Named Insured by blood, marriage or adoption who is a resident of such Named Insured’s household, including a ward or foster child. 2. “Occupying” means in, upon, getting in, on, out or off. 3. “Uninsured motor vehicle” means a land motor vehicle or “trailer”: a. For which no liability bond or policy at the time of an “accident” provides at least the applicable minimum limit for “bodily injury” liability specified in WIS. STAT. ch. 344. The applicable minimum limit is: (1) $50,000 for each “accident”, if the limit of liability is a single limit that applies for each “accident”; or (2) $25,000 for each person/$50,000 for each “accident”, if the limit of liability is indicated as a split limit; b. For which an insuring or bonding company denies coverage or is or becomes insolvent; or c. That is a hit-and-run vehicle and neither the driver nor owner can be identified. The vehi- cle must hit an “insured”, a covered “auto” or a vehicle an “insured” is “occupying”, or must hit another vehicle that hits an “insured”, a covered “auto” or a vehicle an “insured” is “occupying”. d. That is a phantom motor vehicle and neither the driver nor owner can be identified. The vehicle must make no physical contact with the insured nor with a vehicle the insured is occupying, and all of the following must apply: (1) The facts of the accident must be corroborated by competent evidence that is provided by someone other than the “insured” or any other person who makes a claim against the uninsured motorists coverage as a result of the accident; AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, Insurance Services Office, Inc., 2011 CA 21 03 11 11 Page 4 of 4 (2) Within 72 hours after the accident, the “insured” or someone on behalf of the “insured” must report the accident to a police, peace or judicial officer or to the department of transportation or, if the accident occurs outside of Wisconsin, the equivalent agency in the state where the accident occurs; and (3) Within 30 days after the accident occurs, the “insured” or someone on behalf of the “insured” must file with the insurer a statement under oath that the “insured” or a legal representative of the “insured” has a cause of action arising out of the accident for damages against a person whose identity is not ascertainable and setting forth the facts in support of the statement. However, “uninsured motor vehicle” does not include any vehicle: a. Owned by a governmental unit or agency; b. Operated exclusively on rails or crawler treads; c. Designed for use mainly off public roads while not on public roads; d. Owned or operated by a self-insurer under any applicable motor vehicle law, except a self-insurer which is or becomes insolvent; or e. That is an underinsured motor vehicle. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY VALUE GUARD COVERAGE — FIRE DEPARTMENTS AND RESCUE SQUADS POLICY NUMBER: COMMERCIAL AUTO CA 70 27 04 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. WORDS AND PHRASES WITH SPECIAL MEANING 1. “Auto” shall include “permanently attached equipment”. 2. “Permanently attached equipment” means equipment that is welded, bolted or permanently screwed to the dashboard, firewall or body of the “auto”. Equipment inserted on permanently installed slide brackets with or without the use of setscrews or tension shall not be construed as “permanently attached equipment.” B. CHANGE IN PHYSICAL DAMAGE INSURANCE Under Section III — Physical Damage Coverage, with respect to any “auto” identified and scheduled on this endorsement, Paragraphs 1. and 3. of C. Limit of Insurance are deleted and the following is added to this Section: The most we will pay for “loss” in any one “accident” is the lesser of: 1. The cost to repair such covered “auto” or part thereof; 2. The cost to replace a part or parts of the covered “auto” with a part or parts of like kind or quality, without deduction for depreciation; 3. The cost to replace a covered “auto” with a new “auto” of like kind or quality, without deduction for depreciation; or 4. The Limit of Insurance identified in the Value Guard Schedule for the respective covered “auto”. Newly acquired “autos” during the policy period that are not identified in the Value Guard Schedule are not covered under this endorsement. Under Section III — Physical Damage Coverage, with respect to any “auto” identified in the Value Guard Schedule, the following provisions are added to Item C. Limit of Insurance. In addition to the cost of repair or replacement as referenced in Paragraphs B.1. or B.2. above, we will pay up to an additional 50% of the “loss” for the actual costs you incur to render the lost or damaged parts of the covered “auto” to be in compliance with the latest safety or equipment standards mandated by governmental agencies or other nationally recognized standards setting organizations. If, as a result of a covered cause of “loss”, an agency or organization requires recertification of the replaced, lost or damaged parts, we shall also pay those costs. In the event the estimated costs to repair a damaged covered “auto” exceed 75% of the limit shown in the Value Guard Schedule, and you choose not to accept payment under Paragraphs B.1. or B.2. above, we will pay the lesser of the amounts due you under Paragraphs B.3. or B.4. above. Should we make settlement under B.3. or B.4., we shall have the rights to all recovery and salvage. Copyright, 2015 Selective Insurance Company of America. All rights reserved. CA 70 27 04 16 Page 1 of 2 S 2212948 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY VALUE GUARD SCHEDULE Auto No. Year Trade Name Body Type VIN Limit of Insurance Copyright, 2015 Selective Insurance Company of America. All rights reserved. CA 70 27 04 16 Page 2 of 2 1 84 GMC RESCUE UNI 1GUJK34W5EV543168 $33,100 2 85 FORD LOW TILT C 1FDYD80U2FVA35865 $248,000 3 96 PIER PIERCE 4P1CT02U4TA000495 $480,000 4 99 FORD F350 SUPER 1FTSW31F7XEE51211 $126,000 5 00 PETE CONVENTION 2NPNHD8X8YM520638 $330,500 6 02 PIER 1000GPM PU 4P1CT02M92A002273 $480,000 7 06 FORD E450 SUPER 1FDXE45P76HB13981 $173,000 9 08 PIER AERIAL LAD 4P1CI01A480090122 $775,000 10 87 GMC 3000 GAL T 1GDT9C4JHV5303540 $303,300 11 96 KME AERIAL FIR 1K9AF6484TN058357 $999,999 15 06 KOVA FIRE TRUCK 1K9AF42816N058005 $450,000 18 08 CHEV C4500 C4V0 1GBE4V1978F418458 $516,000 19 10 FORD ALS AMBULA 1FDXE4FP3ADA36136 $137,000 21 10 CHEV ALS AMBULA 1GB9G5B66A1122153 $154,000 23 15 PIER PIERCE 4P1BAAFF0FA015003 $516,000 24 14 CHEV EXPRESS CU 1GB6G5CL9E1185647 $170,000 25 16 CHEV ULTRAMEDIC 1GB6UCL4G1339288X $190,000 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY STATED AMOUNT INSURANCE POLICY NUMBER: COMMERCIAL AUTO CA 99 28 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE The insurance provided by this endorsement is reduced by the following deductible(s): Vehicle Number Coverage Limit Of Insurance And Deductible Premium Limit Of Insurance Deductible Limit Of Insurance Deductible Limit Of Insurance Deductible Total Premium NOTE: The amount shown in the Schedule or in the Declarations is not necessarily the amount you will receive at the time of “loss” for the described property. Please refer to the Limit Of Insurance and Deductible Provisions which follow. Designation Or Description Of Covered “Autos” Vehicle Number Model Year Trade Name And Model Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Copyright, Insurance Services Office, Inc., 2009 CA 99 28 03 10 Page 1 of 2 S 2212948 20 COLLISION $484,000 $500 $168.00 20 COMPREHENSIVE $484,000 $500 $41.00 $209.00 20 2010 PIER 1500 GPM PUMPER AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY A. This endorsement provides only those coverages where a premium is shown in the Schedule. Each of these coverages applies only to the vehicles shown as covered “autos”. B. For a covered “auto” described in the Schedule, Physical Damage Coverage — Limit Of Insurance is replaced by the following: Limit Of Insurance 1. The most we will pay for “loss” in any one “accident” is the least of the following amounts: a. The actual cash value of the damaged or stolen property as of the time of the “loss”; b. The cost of repairing or replacing the dam- aged or stolen property with property of like kind and quality; or c. The Limit of Insurance shown in the Sched- ule. 2. An adjustment for depreciation and physical condition will be made in determining actual cash value in the event of a total “loss”. 3. If a repair or replacement results in better than like kind or quality, we will not pay for the amount of the betterment. C. Deductible 1. For each covered “auto”, our obligation to pay: a. The actual cash value of the damaged or stolen property as of the time of the “loss” will be reduced by the applicable deductible shown in the Schedule; b. The cost of repairing or replacing the dam- aged or stolen property with property of like kind and quality will be reduced by the appli- cable deductible shown in the Schedule; or c. The damages for “loss” that would otherwise be payable will be reduced by the applicable deductible shown in the Schedule prior to the application of the Limit of Insurance shown in the Schedule. 2. Any Comprehensive Coverage Deductible shown in the Schedule does not apply to “loss” caused by fire or lightning. Copyright, Insurance Services Office, Inc., 2009 CA 99 28 03 10 Page 2 of 2 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number COMMERCIAL INLAND MARINE DECLARATIONS Policy Effective Date: Coverage Effective Date: Insurance is provided only for those coverages shown in the following coverage schedule. C o v e r a g e S c h e d u l e Coverage Premium Forms and Endorsements: Refer to “Commercial Policy Forms and Endorsement Schedule” Premium Amount (This premium may be subject to adjustment.) CM-7071 (07/94) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 $8,883.00 VESP PORTABLE EQUIPMENT $8,148.00 FLOOD AND EARTHQUAKE COVERAGE $435.00 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY CM-7127 (07/92) Previous Policy Number Policy Number COMMERCIAL INLAND MARINE COVERAGE SUPPLEMENTAL DECLARATIONS VOLUNTEER EMERGENCY SERVICES PORTABLE EQUIPMENT COVERAGE Policy Effective Date: Coverage Effective Date: Insurance is provided only for those coverages for which a specific limit is shown in the following coverage schedule. SCHEDULE LIMITS OF INSURANCE A. SCHEDULED PROPERTY Description of Property Limit of Insurance Total B. UNSCHEDULED PROPERTY C. ALL COVERED PROPERTY AT ALL LOCATIONS DEDUCTIBLE The Deductible amount is $100. unless otherwise stated RATES & PREMIUM Rate Premium A. SCHEDULED PROPERTY B. UNSCHEDULED PROPERTY TOTAL PREMIUM FOR THIS COVERAGE FORM SPECIAL PROVISIONS (If Any) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 2000 RESCUE ONE BOAT #OMCR4915E999 $25,000 2000 JOHNSON BOAT MOTOR #04720566 $9,000 2000 TRANSPORT BOAT TRAILER #4RPBB1615XC009054 $2,000 2009 POLARIS RANGER ATV 4XAHH68A592711522 W/WINCH & FIRE PAL $28,100 2009 ATV TRAILER $2,000 $66,100 $1,826,000 $1,892,100 $1.000 $661.00 $0.410 $7,487.00 $8,148.00 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, American Association of Insurance Services, Inc., 2007 IM 50 01 09 07 SCHEDULE OF EXCLUDED LOCATIONS DIFFERENCE IN CONDITIONS POLICY NUMBER: AAIS IM 50 01 09 07 (The information required below may be indicated on a separate schedule or supplemental declarations) Loc No. Bldg No. Description of Excluded Location S 2212948 002 001 S100W13444 LOOMIS DR MUSKEGO WI 53150 003 001 S76W17858 JANESVILLE RD MUSKEGO WI 53150 004 001 W195S10030 RACINE AVE MUSKEGO WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, American Association of Insurance Services, Inc., 2007 IM 78 06 04 07 LOCATIONS SCHEDULE DIFFERENCE IN CONDITIONS POLICY NUMBER: AAIS IM 78 06 04 07 (The entries required to complete this schedule will be shown below or on the “schedule of coverages”.) Loc No. Bldg No. Description of Covered Location S 2212948 001 001 W144S6731 TESS CORNERS DR MUSKEGO WI 53150 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number COMMERCIAL CRIME COVERAGE DECLARATION Policy Effective Date: Coverage Effective Date: Business of Named Insured: Insurance is provided only for those coverages which are shown in the following coverage schedule. C o v e r a g e S c h e d u l e Coverage Form Coverage Limit Deductible Forms and Endorsements: Refer to “Commercial Policy Forms and Endorsement Schedule” Premium Amount (This premium may be) (subject to adjustemnt.) CR-7026 (02/92) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 VFD $521.00 EMPLOYEE THEFT -SCHEDULED SEE CR0408 SEE CR0408 INSIDE THE PREMISES-ROBBERY/SAFE BURG OTHER PROP $25,000 $500 INSIDE THE PREMISES-THEFT OF MONEY AND SECURITIES $25,000 $500 OUTSIDE THE PREMISES $25,000 $500 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2017 Selective Insurance Company of America. All rights reserved. SCR 04 08 09 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 3 EMPLOYEE THEFT — NAME OR POSITION SCHEDULE POLICY NUMBER: CRIME AND FIDELITY SCR 04 08 09 17 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL CRIME COVERAGE FORM COMMERCIAL CRIME POLICY EMPLOYEE THEFT AND FORGERY POLICY GOVERNMENT CRIME COVERAGE FORM GOVERNMENT CRIME POLICY SCHEDULE Name Schedule Coverage Item No. Names Of Covered Employees Limit Of Insurance On Each Employee Deductible Amount On Each Employee Position Schedule Coverage Item No. Title Of Covered Positions Location Of Covered Positions Number Of Employees In Each Position Limit Of Insurance On Each Employee Deductible Amount On Each Employee Information required to complete this Schedule, if not shown above, will be shown in the Declaration. S 2212948 0001 ALL VOLUNTEERS 1 20 20000 250 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2017 Selective Insurance Company of America. All rights reserved. SCR 04 08 09 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 3 PROVISIONS With regard to this Employee Theft — Name Or Position Schedule Endorsement, the provisions of the coverage form or policy to which this endorsement is attached apply, unless modified by this endorsement. 1. The following insuring agreement is added to Section A. Insuring Agreements: We will pay for loss of or damage to “money”, “securities” and “other property” resulting directly from “theft” committed by an identified “employee”, acting alone or in collusion with other persons. 2. Section B. Limit Of Insurance is replaced by the following: a. The most we will pay for loss resulting directly from an “occurrence” is the applicable Limit of Insurance shown in the Schedule; or b. Regardless of the number of years this insur- ance applies as respects a specific “employee”, the most we will pay in the aggregate is the largest Limit of Insurance applicable to that “em- ployee” even though: (1) The coverage for that “employee” is not continuous because it has been cancelled for one or more periods; or (2) The Limit of Insurance applicable to that “employee” has changed. c. If this insurance applies on a Position Schedule basis, the following conditions also apply: (1) The most we will pay for an “employee” serving in more than one position is the largest Limit of Insurance in effect and applicable to any one of those positions at the time loss is “discovered”. (2) If at the time loss is “discovered” there are more “employees” serving in a covered position than the number of “employees” listed opposite that position in the Schedule, the Limit of Insurance applicable to that position will be reduced. The reduced Limit of Insurance will be computed by multiplying the limit shown in the Schedule by a factor obtained by dividing the number of “employees” shown in the Schedule by the actual number of “employ- ees” serving in that position at the time loss is discovered. 3. Section C. Deductible is replaced by the following: We will not pay for loss in any one “occurrence” unless the amount of loss exceeds the Deductible Amount shown in the Schedule. We will then pay the amount of loss in excess of the Deductible Amount, up to the Limit of Insurance. 4. The following exclusions are added to Section D. Exclusions: This Insuring Agreement does not cover: a. Loss, or that part of any loss, the proof of which as to its existence or amount is dependent upon: (1) An inventory computation; or (2) A profit and loss computation. However, where you establish wholly apart from such computations that you have sus- tained a loss, then you may offer your inventory records and actual physical count of inventory in support of the amount of loss claimed. b. Loss resulting from trading, whether in your name or in a genuine or fictitious account. How- ever, this exclusion shall not apply to loss sustained by an “employee benefit plan”. c. Loss resulting from fraudulent or dishonest signing, issuing, cancelling or failing to cancel, a warehouse receipt or any papers connected with it. However, this exclusion shall not apply to loss sustained by an “employee benefit plan”. 5. Under Section E. Conditions: a. The Consolidation — Merger Or Acquisition Condition does not apply to this Insuring Agreement. b. Paragraph (1) of the Duties in the Event of Loss Condition is replaced by the following: (1) Notify us as soon as possible. c. The Employee Benefit Plan(s) Condition also applies to this Insuring Agreement. All refer- ences to Insuring Agreement A.1. are replaced by this Insuring Agreement. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Copyright, 2017 Selective Insurance Company of America. All rights reserved. SCR 04 08 09 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 3 6. Under Section F. Definitions: a. The definition of “occurrence” is replaced by the following: “Occurrence” means: (1) An individual act; (2) The combined total of all separate acts whether or not related; or (3) A series of acts whether or not related; committed by each “employee” acting alone or in collusion with other persons, during the Policy Period shown in the Declarations, before such Policy Period or both. b. The definition of “employee” is replaced by the following: “Employee” means: (1) Any person named in the Schedule, if cover- age applies on a Named Schedule basis; or (2) Any person you engage to perform the duties of a position shown in the Schedule, if coverage applies on a Position Schedule basis. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Previous Policy Number Policy Number VOLUNTEER EMERGENCY SERVICES MANAGEMENT LIABILITY COVERAGE DECLARATIONS Policy Effective Date: Coverage Effective Date: Named Insured: N O T I C E THIS POLICY PROVIDES CLAIMS-MADE COVERAGE. PLEASE READ THE ENTIRE FORM CAREFULLY. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE APPLICABLE TERMS OF THIS COVERAGE, WE AGREE WITH YOU TO PROVIDE THE INSURANCE COVERAGE STATED IN THIS POLICY. S C H E D U L E 1. Limit of Liability Per “Claim” Limit 2. Annual Aggregate Limit Each Policy Year 3. Deductible Per “Claim” 4. Premium Base: Prior Acts: 5. Retroactive Date Forms and Endorsements: Refer to “Commercial Policy Forms and Endorsement Schedule” Total Advance Premium (This premium may be subject to adjustment.) VS-7005 (10/08) S 2212948 S 2212948 APRIL 1, 2018 APRIL 1, 2018 TESS CORNERS VOLUNTEER FIRE DE $1,000,000 $1,000,000 $0 $1,058.00 N/A APRIL 1, 2016 $1,058.00 AGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPYAGENT’S COPY SELECTIVE INSURANCE COMPANY OF AMERICA 40 WANTAGE AVE, BRANCHVILLE, NJ 07890 S 2212948 S 2212948 SEE COMMERCIAL POLICY COMMON DECLARATION: IL-7025 APRIL 1, 2018 APRIL 1, 2019 SEE COMMERCIAL POLICY COMMON DECLARATION: IL-7025 00-48177-00000 ASSN/LABOR/RE VFD $3,000,000.00 $3,000,000.00 $.00 $200.00 $2,812.00 APRIL 3, 2018 HEARTLAND REGION S 221294802 SELECTIVE INS CO OF AMERI APRIL 1, 2018 APRIL 1, 2019 $10,000,000 $10,000,000 $4,000,000 $4,000,000 S 221294802 SELECTIVE INS CO OF AMERI APRIL 1, 2018 APRIL 1, 2019 $1,000,000 SEE FORMS AND ENDORSEMENT SCHEDULE: IL-7035 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY Coverage Effective Date Policy Number DECLARATIONS – COMMERCIAL UMBRELLA LIABILITY COVERAGE SCHEDULE OF UNDERLYING INSURANCE AND LIMITS EXTENSION Policy No. Company Policy Period From: To: Policy No. Company Policy Period From: To: Policy No. Company Policy Period From: To: Policy No. Company Policy Period From: To: Policy No. Company Policy Period From: To: Policy No. Company Policy Period From: To: CX-0004 (01/99) APRIL 1, 2018 S 2212948 Vesp DO/Admin EO S 221294802 SELECTIVE INS CO OF AMERI APRIL 1, 2018 APRIL 1, 2019 AGGREGATE LIMIT: $1,000,000 PER CLAIM LIMIT: $1,000,000 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY SCHEDULED POLICY FOLLOWING FORM LIABILITY COVERAGE ENDORSEMENT POLICY NUMBER: COMMERCIAL UMBRELLA LIABILITY CXL 338 08 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA LIABILITY COVERAGE PART The following is added to SECTION I — COVERAGES, A. INSURING AGREEMENT: 7.Excess Following Form Liability Coverage Over Underlying Claims Made or Occurrence Coverage for Scheduled Policies: a.We will pay, on behalf of the insured, the “ultimate net loss” in excess of the Limits of Liability of the “underlying insurance” listed in the Declarations for the Schedule of Policies listed below provided that: (1) The “ultimate net loss” is caused by an “occurrence” happening in the “coverage territory” during the policy period; and (2) Coverage must be afforded by the Schedule of Policies or coverage would have been afforded but for the exhaustion of the Limit of Liability shown in the Declarations for the Schedule of Policies. b.The Limits of Liability of the “underlying insurance” for the Schedule of Policies will apply even if: (1) The “underlying insurer” claims the insured failed to comply with any condition of the policy, or (2) The “underlying insurer” becomes bankrupt or insolvent. Coverage under this Endorsement will not apply to any “ultimate net loss” for which coverage exists under any other provision of this policy nor shall the Limit of Insurance of this policy be increased as a result of the existence of this Endorsement. Coverage under this Endorsement follows the form of the Schedule of Policies and is subject to the same terms, conditions, agreements, exclusions and definitions as those contained in the Schedule of Policies unless otherwise provided in this Coverage Part or its endorsements. SECTION V — DEFINITIONS: The definition of “occurrence” is amended to include damages and/or wrongful acts as defined by the underlying scheduled policy. Schedule of Policies Policy Number Issuing Company Policy Coverage Part Title Policy Period CXL 338 08 04 S 2212948 S 221294802 SELECTIVE INS CO OF AMERI Vesp DO/Admin EO 04/01/2018-04/01/2019 AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY POLICY SCHEDULE Policy No Issued To Period Transaction Type Agent Number Billing Type Transaction Eff. Date Number of Remaining Installments MISC-1591 (02/16) SELECTIVE INSURANCE BRANCHVILLE, NEW JERSEY 07890 ISSUE DATE: 04/04/2018 S 2212948 TESS CORNERS VOLUNTEER FIRE DEPARTMENT 04/01/2018 04/01/2019 RENEWAL 00-48177-00000 DIRECT BILL 04/01/2018 04 PAYMENT WILL BE BILLED AS FOLLOWS: BILL ACCOUNT: 305 908 390 BILLING DATES PREMIUM AMOUNTS BILLING DATES PREMIUM AMOUNTS 01. 04/17/2018 8,430.00 02. 06/17/2018 8,430.00 03. 09/17/2018 8,430.00 04. 12/18/2018 8,427.00 TOTAL PREMIUM AMOUNT $33,717.00 C O M M I S S I O N N O T I C E --------- TOTALS -------- RATE PREMIUM COMMISSION 15.00% 17,357.00 2,603.55 17.00% 1,058.00 179.86 20.00% 15,302.00 3,060.40 TOTALS $33,717.00 $5,843.81 Your bill will be sent under separate cover. This is a Payment Schedule of your policy premium due based on your selected installment plan. Changes made to the policy premium after the issue date listed above, will be reflected on future bills. An installment fee of $6.00 may be added to each installment bill. Policies not paid by the installment due date may be subject to a late fee of $20.00 for each late payment. An insufficient fund fee of $25.00 will be charged for payments returned by your financial institution. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY IMPORTANT NOTICE ABOUT YOUR PAYMENT PLAN AND LATE PAYMENTS UNDER YOUR PAYMENT PLAN: If you have selected a payment plan option to pay for Your policy or policies with Us, we will send You a bill or email notification when premium is due. Bills will show (1) the billed minimum amount due on Your account for that month, and (2) the total balance due on Your account, including late and installment fees, if any have been charged. On or before the due date We specify in Your bill, You will be required to pay Us the total billed minimum amount shown in order to stay current in your payments due to Us (excluding any policy or policies that are pending cancellation). Any time a payment is late and You fall behind on the amount that is owed to Us for the policy premium, we will issue a policy cancellation notice for failure to pay the premium, and we may charge you a late fee. For the first two times you fall behind, if You pay the total amount due before the cancellation effective date indicated in the notice, the policy or policies will remain in effect. If, however, We issue a third cancellation notice for nonpayment of premium, We will accelerate the remaining payments due under the payment plan and require You to pay the full outstanding policy premium (not just the total billed minimum amount in the most recent bill) on or before the cancellation effective date. If You do not pay the full outstanding balance on or before the cancellation effective date, We will cancel Your policy. If Your policy or policies are cancelled or expired, Your enrollment in an electronic payment option will continue, despite the fact that the policy(s) have been cancelled with Selective and may remain in effect until such time as any payment for any earned premiums, audit balances or other amounts related to your account are settled. If more than one policy is subject to a payment plan, We will apply partial payments proportionately to the billed minimum amount for each policy. Any policy that is not paid in full after this allocation will be subject to cancellation for nonpayment of premium, as provided in the policy. Selective Insurance Main Administrative Offices 40 Wantage Avenue Branchville New Jersey 07890 (973) 948-3000 “Selective Insurance” refers to the following affiliated insurers: Selective Insurance Company of America, Selective Way Insurance Company, Selective Insurance Company of South Carolina, Selective Insurance Company of the Southeast, Selective Insurance Company of New York, Selective Insurance Company of New England, Selective Casualty Insurance Company, Selective Fire and Casualty Insurance Company, and Selective Auto Insurance Company of New Jersey. The declarations page of your policy identifies the insurance carrier that issued your “Selective Insurance” policy. AGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPYAGENT'S COPY