# CHUBB Commercial General Liability Declarations

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

**POLICY NUMBER:** HDO G71237606

| Endt. No. | Form No. | Description |
|-----------|----------|-------------|
| 161       | IL01990908 | Arkansas Changes - Transfer Of Rights Of Recovery Against Others To Us |
| 162       | IL02280907 | Colorado Changes - Cancellation And Nonrenewal |
| 163       | IL02600119 | Connecticut Changes – Cancellation And Nonrenewal |
| 164       | IL01400908 | Connecticut Changes - Civil Union |
| 165       | IL01510112 | Delaware Changes - Civil Union |
| 166       | IL02370412 | Delaware Changes - Termination Provisions |
| 167       | IL02040908 | Idaho Changes - Cancellation And Nonrenewal |
| 168       | IL01470911 | Illinois Changes - Civil Union |
| 169       | IL01580908 | Indiana Changes |
| 170       | IL02720907 | Indiana Changes - Cancellation And Nonrenewal |
| 171       | IL01171210 | Indiana Changes - Workers' Compensation Exclusion |
| 172       | IL09130498 | Insurance Inspection Services Exemption From Liability |
| 173       | IL02760908 | Iowa Changes - Cancellation And Nonrenewal |
| 174       | IL02630908 | Kentucky Changes - Cancellation And Nonrenewal |
| 175       | IL02770118 | Louisiana Changes – Cancellation And Nonrenewal |
| 176       | IL02470211 | Maine Changes - Cancellation And Nonrenewal |
| 177       | IL01360504 | Mandatory Premium And Coverage Conditions Endorsement - Puerto Rico |
| 178       | IL02860417 | Michigan Changes – Cancellation And Nonrenewal |
| 179       | IL02450908 | Minnesota Changes - Cancellation And Nonrenewal |
| 180       | IL02820908 | Mississippi Changes - Cancellation And Nonrenewal |
| 181       | IL02430907 | Montana Changes |
| 182       | IL02510907 | Nevada Changes - Cancellation And Nonrenewal |
| 183       | IL01150110 | Nevada Changes - Domestic Partnership |
| 184       | IL01350119 | New Hampshire Changes – Cancellation And Nonrenewal |
| 185       | IL01450908 | New Hampshire Changes - Civil Union |
| 186       | IL02080907 | New Jersey Changes - Cancellation And Nonrenewal |
| 187       | IL01410908 | New Jersey Changes - Civil Union |
| 188       | IL00230702 | Nuclear Energy Liability Exclusion Endorsement (Broad Form) |
| 189       | IL02440907 | Ohio Changes - Cancellation And Nonrenewal |
| 190       | IL02360907 | Oklahoma Changes - Cancellation And Nonrenewal |
| 191       | IL02790908 | Oregon Changes - Cancellation And Nonrenewal |
| 192       | IL01420908 | Oregon Changes - Domestic Partnership |
| 193       | IL02460907 | Pennsylvania Changes - Cancellation And Nonrenewal |
| 194       | IL01970908 | Rhode Island Changes |
| 195       | IL01610312 | Rhode Island Changes - Civil Union |
| 196       | IL01280908 | Rhode Island Changes - Prejudgment Interest |

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