**GENERAL LIABILITY INSURANCE COVERAGE SCHEDULE**

**CA 8570500**
**EFFECTIVE DATE:** [Not specified]
**AGENCY NO.:** [Not specified]

**Location of all premises owned by, rented to or controlled interest of named insured in such premises (Enter "SAME" if same as Item I or Declarations):**
- **OWNER:** "GENERAL LESSEE" OR "TENANT"
- **Part occupied by named insured:** [Not specified]

**AS PER SCHEDULES IN COMPANY FILES**
**AS PER SCHEDULES IN COMPANY FILES**
**AS NECESSARY**

| DESCRIPTION OF HAZARDS | CODE NO. | PREMIUM BASES | RATES | ADVANCE PREMIUMS |
|------------------------|----------|---------------|-------|-------------------|
| Premises—Operations   |          |               |       |                   |
| (a) Area (sq. ft.)    | (b) Frontage | (c) Description | (a) Per 100 sq. ft. of Area | (b) Per linear ft. of Remuneration | (c) Per step of Remuneration | (d) Per $100 of Cost | (e) Per $1,000 of Receipts | (f) Per $1,000 of Sales | Total Advance Premium $ |
| AS PER SCHEDULES IN COMPANY FILES | | | | | | | | | |
| Elevators (Number at Premises) | | Number Insured | Per Elevator | | | | | | |
| AS PER SCHEDULES IN COMPANY FILES | | | | | | | | | |
| Independent Contractors | | Cost | Per $100 of Cost | | | | | | |
| AS PER SCHEDULES IN COMPANY FILES | | | | | | | | | |
| Completed Operations | | (a) Receipts | (a) Per $1,000 of Receipts | | | | | | |
| AS PER SCHEDULES IN COMPANY FILES | | | | | | | | | |
| Products | | (b) Sales | (b) Per $1,000 of Sales | | | | | | |
| AS PER SCHEDULES IN COMPANY FILES | | | | | | | | | |

The foregoing discloses all hazards insured hereunder known to exist at the effective date of this policy, unless otherwise stated herein.
(Continued on reverse side)

Form No. 551
Z 006986