2016-08-29_PERMIT FILE - C1981035A ‎(45)‎

• Permit No: C1981035A
• IBM Index Class Name: PERMIT FILE
• Doc Date: 8/29/2016
• Doc Name: Insurance: Personal Injury & Property Damage
• Section_Exhibit Name: KI Appendix 14
• Media Type: D
• Archive: Yes

Policy Number
G LO 6551241-05
THIS ENDORSEMENT CHANGES THE POLICY.
PLEASE READ IT CAREFULLY.
COMMON POLICY CHANGE ENDORSEMENT
Endorsement No. 001
AMERICAN ZURICH INSURANCE COMPANY
Named Insured GCC ENERGY LLC Effective Date: 09-01-14
12:01 A.M., Standard Time
Agent Name AON RISK SERVICES SOUTHWEST, INC. Agent No. 14340-000
This endorsement will not be used to decrease coverages, increase rates or deductibles or alter any terms or
conditions of coverage unless at the sole request of the insured.
COVERAGE PART INFORMATION —Coverage parts affected by this change as indicated by ff] below.
❑ Commercial Property
❑ Commercial General Liability NO CHARGE
❑ Commercial Crime
❑ Commercial Inland Marine
El
The following item(s):
F7Insured's Name 17 Insured's Mailing Address
Policy Number F7 Company
71 Effective/ Expiration Date F-1 Insured's Legal Status/Business of Insured
F1Payment Plan F7 Premium Determination
Additional Interested Parties ❑ Coverage Forms and Endorsements
aLimits/ Exposures F-1 Deductibles
aCovered Property/ Location Description FI Classification/ Class Codes
E] Rates E] Underlying Exposure/ Insurance
is (are) changed to read {See Additional Page(s)I
THE FOLLOWING FORM(S) HAS BEEN ADDED:
U—GL-1447—A CW 05-10 NOTIF TO OTHERS OF CANC NONR OR REDUCT
The above amendments result in a change in the premium as follows:
This premium does not include taxes and surcharges.
© No Changes To be Adjusted at Audit Additional NO CHARGE ReturnNO CHARGE
Tax and Surcharge Changes
Additional Return
Countersigned By:
AUTHORIZED AGENT
U -GU -614A CW (10/02)