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COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy No. SE 2004000 Effective Date: 06/19/2021 <br />12:01 STANDARD TIME <br />LIMITS OF INSURANCE <br />Each Occurrence Limit $1,000,000 <br />Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000 <br />Medical Expense Limit (Any One Person) $1,000 <br />Damages To Premises Rented To You (Any One Premises) $100,000 <br />Products/Completed Operations Aggregate Limit See L-535 <br />General Aggregate Limit $3,000,000 <br />LIABILITY DEDUCTIBLE $0 <br />LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY <br />Location Address Territory <br />1 533 N Niles Ave, South Bend, IN 46617 004 <br />PREMIUM COMPUTATION <br />Advance Premium <br />Evr # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other <br />1 Sporting Event / Tournament - Running Events (5K, 00413 500 Attendees N/A 253.000 N/A <br />$253 <br />8K, & 1 OK) (applicant is the host of the event) <br />1 Additional Insured - Blanket - Special Events 49950 1 Per Additional N/A 0 000 N/A <br />$0 <br />Insured <br />1 Additional Insured - Property Owner or Lessors of 49950 1 Per Additional N/A 0.000 N/A <br />$0 <br />Premises Insured <br />MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART: <br />$195 <br />TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART: <br />$253 <br />(This Premium may be subject to adjustment.) MP - minimum premium <br />Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue: <br />See Form EOD (01/95) and Form SOE (03/10) <br />THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. <br />Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission. <br />