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°' GECLFIAA i IONS SGFiLUULE --iSEi!L;N!LL LL^•'flLl I Y H,`+ZARIJS <br />~ +t~~> i~ ~ AND PFlEWISES MEDICAL PAYMENTS ENDORSEPAENT <br />~•.. fC ~ <br />llart~ud tnsurud ....................... ......... .................. ..... .. .. ..... ...................... <br />1( <br />Etfeclive Date .....................................................Policy NO.......................... ~'......fAY `;~~!`~.7.•'~.V..+.. <br />~Authorizc0 Agen <br /> Rates Depose Premiums <br />, <br />Description of Hexards Code No. Premium Bases Bodily <br />Injury Property <br />Damege Botllly <br />Injury Property <br />Dart~ege <br /> Lleblllly Llablllly Lleblllty LIeDI11Iy <br />` The iahng classd~cal~ons under the Descrlplion of Ha=arils do not motlity (a) Are9 (a} Per 100 S q. F7 Area S S <br />the Cnclusigns or e1hM teems of the policy. (b) Frontage (b) Per Linea l FOOT <br /> <br />(a) Premises-Ope=ebons c Rem unerafion <br />( ) (c) Pei 5100 Remuneration <br /> (d) Receipts (d) Per 5100 Receipts <br />A'_ning - ~>uzface 1400ia )300,000, .699 incl. 2079.00 incl. <br />era" loading c~arge .528 1534.00 <br />(b) Escalators Number Per L anding <br />i;one at inception <br />(c) Indepentlent Contractors Cost Per 5100 0l Cosl <br />If any, to be determined by audit <br />(d} Completed Operations Per 57,00 0 of Receipts <br />*:ot covered <br />(e) Products Per St.00 0 0l Sales <br />?dot covered <br /> Premium Sub-Total 5209] . UO 158'. ._~_ <br />Limits a l Liability COVERAGE E - la) Premises and Operations 5 <br />Each Person Each Fcddent ppEMISES <br /> MEDICAL <br />s 1 000. s 25,000. PAYMENTS 14001a 65.00 _ _ _ <br /> (See Provisions (b) Escalators 5 <br /> on Reverse Side) (c) Sports Activities 5 <br />COD tY ~CLOr'9 Lrduipaent _ _^ sh lao. uv_ _ _ __ <br />--- 5 - <br />10-2^,-83 ilk ~ cE~:EP~L. >BiLITY DEPOSIT PREt.UUld s4i^F,n~ - <br />