# Commercial General Liability Declarations

**CHUBB**

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

**POLICY NUMBER:** HDO G48898919

| Endt. No. | Form No. | Description |
|-----------|----------|-------------|
| 159       | CG01240193 | Wisconsin Changes - Amendment Of Policy Conditions |
| 160       | IL02311022 | Arkansas Changes - Cancellation And Nonrenewal |
| 161       | IL01990908 | Arkansas Changes - Transfer Of Rights Of Recovery Against Others To Us |
| 162       | IL02700720 | California Changes – Cancellation And Nonrenewal |
| 163       | IL02280907 | Colorado Changes - Cancellation And Nonrenewal |
| 164       | IL02040908 | Idaho Changes - Cancellation And Nonrenewal |
| 165       | IL01470911 | Illinois Changes - Civil Union |
| 166       | IL01580908 | Indiana Changes |
| 167       | IL02721121 | Indiana Changes – Cancellation And Nonrenewal |
| 168       | IL01171210 | Indiana Changes - Workers' Compensation Exclusion |
| 169       | IL02630908 | Kentucky Changes - Cancellation And Nonrenewal |
| 170       | IL02771020 | Louisiana Changes - Cancellation And Nonrenewal |
| 171       | IL02860417 | Michigan Changes – Cancellation And Nonrenewal |
| 172       | IL02450908 | Minnesota Changes - Cancellation And Nonrenewal |
| 173       | IL02820908 | Mississippi Changes - Cancellation And Nonrenewal |
| 174       | IL02430907 | Montana Changes |
| 175       | IL02080907 | New Jersey Changes - Cancellation And Nonrenewal |
| 176       | IL01410908 | New Jersey Changes - Civil Union |
| 177       | IL00230702 | Nuclear Energy Liability Exclusion Endorsement (Broad Form) |
| 178       | IL00230702 | Nuclear Energy Liability Exclusion Endorsement (Broad Form) |
| 179       | IL02440907 | Ohio Changes - Cancellation And Nonrenewal |
| 180       | IL02790908 | Oregon Changes - Cancellation And Nonrenewal |
| 181       | IL01420908 | Oregon Changes - Domestic Partnership |
| 182       | IL02500908 | Tennessee Changes - Cancellation And Nonrenewal |
| 183       | IL01680312 | Texas Changes – Duties |
| 184       | IL02660721 | Utah Changes – Cancellation And Nonrenewal |
| 185       | IL02830907 | Wisconsin 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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