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
BAP 6551242-05
THIS ENDORSEMENT CHANGES THE POLICY.
PLEASE READ IT CAREFULLY.
COMMON POLICY CHANGE ENDORSEMENT
Endorsement No. 002
ZURICH AMERICAN 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
nCommercial General Liability
F] Commercial Crime
❑ Commercial Inland Marine
r7-1
BUSINESS AUTOMOBILE NO CHARGE
11
The following item(s):
Insured's Name Insured's Mailing Address
aPolicy Number a Company
Effective/ Expiration Date F Insured's Legal Status/Business of Insured
Payment Plan F Premium Determination
Additional Interested Parties ❑ Coverage Forms and Endorsements
Limits/ Exposures F7 Deductibles
Covered Property/ Location Description F-1 Classification/Class Codes
0 Rates 0 Underlying Exposure/ Insurance
is (are) changed to read (See Additional Page(s) )
THE FOLLOWING FORM(S) HAS BEEN ADDED:
U—CA-811—A CW 05-10 NOTIF TO OTHERS OF CANC NONRNW RED
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
I Additional NO CHARGE
ReturnNO CHARGE
Tax and Surcharge Changes
Additional Return
Countersigned By:
AUTHORIZED AGENT
U -GU -614-A CW (10/02)