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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number: PHPK267695 <br />Agent # 17921 <br />® See Supplemental Schedule <br />LIMITS OF INSURANCE <br />Premium <br />Basis <br />$ 1,000,000 <br />General Aggregate Limit (Other Than Products—Completed Operations) <br />$ 1,000,000 <br />Products/Completed Operations Aggregate Limit (Any One Person Or Organization) <br />$ 1,000,000 <br />Personal and Advertising Injury Limit <br />$ 1,000,000 <br />Each Occurrence Limit <br />$ 100, 000 <br />Rented To You Limit <br />$ 5, 000 <br />Medical Expense Limit (Any One Person) <br />FORM OF BUSINESS: NON PROFIT ORGANIZATION <br />Business Description: Non Profit Organization <br />Location of All Premises You Own, Rent or Occupy: SEE SCHEDULE ATTACHED <br />AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STATED: N/A <br />Classifications Code No. <br />Premium <br />Basis <br />Rates <br />PremJ ProdJ <br />Ops. Como. ops <br />Advance Premiums <br />PremJ Prod.! <br />ops. Comp. ops. <br />SEE SCHEDULE ATTACHED <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br />$ 173.00 <br />$ <br />RETROACTIVE DATE (CG 00 02 ONLY) <br />This insurance does not apply to "Bodily Injury", "Property Damage", or "Personal and Advertising Injury" which <br />occurs before the retroactive date, if any, shown below. <br />Retroactive Date: <br />FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br />Countersignature Date Authorized Representative <br />