# Commercial General Liability Declarations

**CHUBB**

**ACE American Insurance Company**
436 Walnut Street
Philadelphia PA

**POLICY NUMBER:** HDO G72490587

| Endt. No. | Form No. | Description |
|-----------|----------|-------------|
| 192       | IL02790908 | Oregon Changes - Cancellation And Nonrenewal |
| 193       | IL01420908 | Oregon Changes - Domestic Partnership |
| 194       | IL02460907 | Pennsylvania Changes - Cancellation And Nonrenewal |
| 195       | IL01970908 | Rhode Island Changes |
| 196       | IL01610312 | Rhode Island Changes - Civil Union |
| 197       | IL01280908 | Rhode Island Changes - Prejudgment Interest |
| 198       | IL02490719 | South Carolina Changes – Cancellation And Nonrenewal |
| 199       | IL02320908 | South Dakota Changes - Cancellation And Nonrenewal |
| 200       | IL02500908 | Tennessee Changes - Cancellation And Nonrenewal |
| 201       | IL01680908 | Texas Changes - Duties |
| 202       | IL02660908 | Utah Changes - Cancellation And Nonrenewal |
| 203       | IL01090908 | Vermont Changes - Civil Union |
| 204       | IL01260908 | Vermont Changes - Statutory Liability |
| 205       | IL02810489 | West Virginia Changes - Cancellation |
| 206       | IL02830907 | Wisconsin Changes - Cancellation And Nonrenewal |
| 207       | IL02520907 | Wyoming Changes - Cancellation And Nonrenewal |

**THE TOTAL AMOUNT DUE INCLUDES A PREMIUM SURCHARGE PURSUANT TO SECTION 136.392 OF THE KENTUCKY REVISED STATUTES.**

LD-25211 (10/08)
Copyright, Insurance Services Office, Inc. 2000
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