2016-08-29_PERMIT FILE - C1981035A ‎(46)‎

• Permit No: C1981035A
• IBM Index Class Name: Permit File
• Doc Date: 8/29/2016
• Section_Exhibit Name: KII Appendix 14 Certificate of Liability Insurance
• Media Type: D
• Archive: Yes

Policy Number
GLO 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 x❑ below.
Commercial Property
❑ Commercial General Liability NO CHARGE
❑ Commercial Crime
FICommercial Inland Marine
The following item(s):
Insured's Name Insured's Mailing Address
Policy Number Company
Effective/ Expiration Date Insured's Legal Status/Business of Insured
Payment Plan Premium Determination
MAdditional Interested Parties Coverage Forms and Endorsements
F7Limits/ Exposures F-1 Deductibles
71 Covered Property/ Location Description F-1 Classification/Class Codes
EjRates 0 Underlying Exposure/ Insurance
is (are) changed to read (See Additional Page(s))
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 prerniurn does not include taxes and surchar es.
No Changes 10 To be Adjusted at Audit I Additional NO CHARGE ReturnNO CHARGE
Tax and Surcharge Changes
Additional Return
Countersigned By:
AUTHORIZED AGENT
U -GU -614-A CW (10/02)