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` LLD GO 24 74 42 4 <br />INSURANCE COMPANY OF NORTH AMERICA <br />1600 ARfi STREET. PHILADELPHIA. PENNSYLVANIA 19101 <br />LITTLE LEAGUE GENERAL LIABILITY POLICY <br />LITTLE LEAGUE GENERAL LIABILITY POLICY NO. <br />DECLARATIONS <br />Item 1. Named Insured. P.O. Address, and location of operations of Insured: <br />Santa Ana Southwest Little League <br />Santa Ana, Ca. <br />a registered Little League of Little League Baseball, Incorporated of Williamsport, Pennsylvania. <br />Item 2. Additional Insureds, if any, as respects premises loaned. donated or rented to the Named Insured Little League named in Item I of these <br />declarations <br />NAME AND ADDRESS NAME AND ADDRESS <br />b. XX? ? e <br />Item 3. The premium for this policy is 5 ....... 410.00 .......... _..._..._._, computed on the basis of the following fixed charges: <br />Bass charges for Nameo <br />Insured idenufled in <br />Hem 1, above. <br />Leagues wlihout a "Senor Division" I Leagues with a "Senor Division" <br />(Excluding Soft- i (Including Soft (Excluding Soft- (Including Solt <br />bail Program) ball Program) ball Program) ball Program) <br />$215.00 $310.00 $290.00 $385.00 <br />Surcharge for each "Big League" Team: $30.00 <br />Charge for each additional insured name.] in Item 260. <br />above _.. _.. ..... _......_ __.__5 i5. cc <br />Charge. d any. for Non Cwneo or Nired Auto 5 <br />Item 4. Term of policy. From.... ..... Starch 1.L% t ._.._. _...___..10 January 1, 10 <br />12'.01 A.M , standard time at the Insured's address. <br />Item 5. Coverage is afforded in accordance with the attached Little League General Liability Policy. The limit of the Company's liability for each <br />coverage shall be as stated herein, subject to all the terms of the policy having reference thereto_ <br />Coverage A Coverage 8 <br />Bodily Injury Liability — $300,000 each occurrence Property Damage Liability — $25,000 each occurrence <br />l $300,000 aggregate $25,000 aggregate <br />Item 6. Form number(s) of ormted endorsement(s) attached to policy at inception dater \ <br />OY Rlr e FOR Y HTCL -Aga E IYCL ")I'1 ' D9 <br />'IV 1 C_ o711 3 <br />iOiLRi S 4, R J?'I CLuJ 2A2XED A. . L.1_SfA:1 S '�— .. - - - -- <br />?LACE OF EUSI ?TeCC OR 3 <br />= "TDTNC^ <br />This Declarations Page, :he Little League General Liability Policy form and attached Endorsements issued to form a part hereof rom- <br />plele the above numeered polic/. <br />LD -C97 B Pro. in U A. (E1 9 85 CA. FL. NJ. NY) <br />