# Allianz

## Item 6. Notice to: (Conditions 3 and 4)
a. All Notices of Occurrence:
   - Allianz Global Risks US Insurance Company
     - 225 West Washington Street, Suite 1800
     - Chicago, Illinois 60606-3483
     - Attention: Claims Department

b. All Other Notices:
   - Allianz Global Risks US Insurance Company
     - 225 West Washington Street, Suite 1800
     - Chicago, Illinois 60606-3483
     - Attention: Liability Underwriting

## Item 7.
a. Premium without TRIPRA: USD $
b. TRIPRA Premium: USD $
c. Total Premium (with TRIPRA): USD $ (for 100% Flat Annual)
d. Minimum Earned Premium: USD $ <Not Applicable in Montana>

## Item 8. The Company:
   - Allianz Global Risks US Insurance Company
     - 225 West Washington Street, Suite 1800
     - Chicago, IL 60606-3484

## Item 9. Producer:
   - Producer Name >
   - Producer Address >

## Item 10. Policy Form:
   - Excess Liability Following Form Short Excess Form
     - Form Number AGRL XS ASF 2000 10 20
   - Endorsements:
     - As per Forms and Endorsement List attached to this Policy.

AGRL XS ASF 1000 10 20
Copyright © 2020 Allianz Global Risks US Insurance Company. All rights reserved.
Contains copyrighted material of AON Risk Services, AON Risk Solutions and AON, plc used with their permission.
Page 2 of 2