HomeMy WebLinkAboutFire Union Hall 558 ACUITY
BIS -PAK®
A Mutual Insurance Company COVERAGE PART
a)
Renewal Declarations
First Named Insured and Address:
Agency Name and Number:
UNION HALL 558 0
TAGGART INSURANCE CENTER, INC '—
PO BOX 594 7181 AA D
JEFFERSONVLLE IN 47131
Policy Number: X30915
Policy Period: Effective Date: 12 -07 -12
Expiration Date: 12 -07 -13
In return for the payment of the premium and subject to 12:01 A.M. standard time at
all the terms of the policy, we agree to provide the your mailing address shown
insurance coverage as stated in the same. in the declarations
C
17.5
COVERAGE FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART
Form Number Form Title
Premium
CB -0006 (12 -11) Bis -Pak Business Liability and Medical Expenses Coverage Form $
CB -0009 (09 -04) Bis -Pak Common Policy Conditions
CB -1416 (01 -10) Snow Plow Products - Completed Operations Hazard Coverage
CB -7029 (09 -04) Personal and Advertising Injury Exclusion
CB -0417 (07 -02) Employment - Related Practices Exclusions
CB -0577 (04 -10) Fungi or Bacteria Exclusion (Liability)
CB-0601R (01 -07) Exclusion of Loss Due to Virus or Bacteria
CB -1004 (01 -07) Exclusion of Certain Computer - Related Losses
CB -1445 (12 -10) Indiana Changes - Workers' Compensation Exclusion
CB -7112 (09 -04) Indiana Changes
CB -7262 (04 -10) ACUITY Advantages - Property Coverages
CB -7264 (04 -10) ACUITY Advantages - Liability Coverages
IL -0156F (07 -89) Indiana Changes - Concealment, Misrepresentation or Fraud
IL -7012 (11 -11) Asbestos Exclusion
IL -7015 (01 -02) Indiana Changes - Cancellation and Nonrenewal
CB -7296 (01 -08) Cap on Losses from Certified Acts of Terrorism - Property 21.00
CB-7298 (01 -08) Exclusion of Punitive Damages Related to a Certified Act of
Terrorism
CB -7299 (01 -08) Cap on Losses from Certified Acts of Terrorism - Liability 1.00
IL -7082 (01 -08) Disclosure Pursuant to Terrorism Risk Insurance Act
CB -0002 (12 -11) Deluxe Bis -Pak Property Coverage Form
CB -0402 (01 -87) Additional Insured - Managers or Lessors of Premises
Advance Endorsement Premium $ 22.00
CB- 7000(12 -08) Agency Copy
SO 01 11/05/12
2407
Page 2
Policy Number: X30915
Effective Date: 12 -07 -12
PREMIUM SUMMARY
Advance Premium
Advance Endorsement Premium 848.00
22.00
Total Advance Premium
870.00
The Total Advance Premium shown above is based on the exposures you anticipated a
coverage part began. We will audit this coverage part in accordance with the Bis -Pak® t the time this Liability and Medical
Expenses General Condition entitled Premium Audit - Business Liability at the close of the a
udit period.
PROPERTY COVERAGES PROVIDED
Form: Deluxe
Coverage Premises Building
Item Number Number Valuation Limit of Automatic
Basis Insurance Increase
– — — Percentage
Building 001 001
Replacement Cost $ 265,000 6%
Business Personal Property 001 001
Replacement Cost 25,000 N/A
Deductible: $1,000
DESCRIPTION OF PREMISES
Premises Building
Construction,
Number Number
Occupancy and Location
001 001 JOISTED MASONRY
LABOR UNION OFFICES
11TH MECHANIC
JEFFERSONVILLE IN
MORTGAGEHOLDER NAME AND ADDRESS
NONE
CB 7000(12 -08)
SO 01 11/05/12
Page 3
Policy Number: X30915
Effective Date: 12 -07 -12
LIABILITY COVERAGES PROVIDED
Coverage Item
Limit of
Insurance
Liability and Medical Expenses (Each Occurrence)
$ 300,000
Medical Expenses (Any One Person)
5,000
Damage to Premises Rented to You
100,000
Products - Completed Operations Aggregate Limit
1,000,000
General Aggregate Limit (Other Than Products - Completed Operations)
1,000,000
SCHEDULE OF LIABILITY CLASSIFICATIONS
Premises Building Classification Class Premium Rate
Number Number Description Code '
Basis
001 001 Office Buildings 61226 1,700 AR 77.16
1 AR = Area - Rate Applies Per 1,000 Square Feet
_._ OPTIONAL COVERAGES PROVIDED
Coverage Item
Insuranc Limit of e
Forgery and Alteration
$ 2,500
Business Income from Dependent Properties
5,000
Electronic Data
10,000
Interruption of Computer Operations
Outdoor Signs
10, 000
10,000
ACUITY Advantages - Liability Coverages
See CB -7264
ACUITY Advantages - Property Coverages
See CB -7262
Coverage Item Premises Building Limit of
Number Number Insurance
Business Income and Extra Expense 001 001 Actual Loss
Sustained
Landlord as an Additional Insured 001 001
Same as
Liability Limit
Money and Securities 001 001
Inside the Premises
Outside the Premises
$ 10,000
5,000
Accounts Receivable 001 001
25,000
Valuable Papers 001 001 10,000
BIS -PAK® PLAN
Offices
CB- 7000(12 -08)
SO 01 11/05/12
ENDORSEMENTS
ADDITIONAL INSURED — MANAGERS OR LESSORS OF PREMISES
CB- 0402(1 -87)
This endorsement modifies insurance provided under 2. The following exclusions are added:
the following:
BIS -PAK® BUSINESS LIABILITY AND MEDICAL This insurance does not apply to:
EXPENSES COVERAGE FORM a. Any occurrence that takes place after you cease
1. The following is added to Who Is an Insured: to be a tenant in the premises described in the
Schedule.
The person or organization shown in the Schedule is
also an insured, but only with respect to liability b. Structural alterations, new construction or demoli-
arising out of the ownership, maintenance or use of tion operations performed by or for the person or
that part of the premises leased to you and shown in organization designated in the Schedule.
the Schedule.
SCHEDULE
Person or Organization Designation of Premises
(Name and Address) (Part Leased to You)
CITY OF JEFFERSONVILLE 11TH MECHANIC
CITY COUNTY BLDG RM 416 JEFFERSONVILLE IN
JEFFERSONVILLE IN 47130
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