**COMPREHENSIVE GENERAL LIABILITY INSURANCE COVERAGE SCHEDULE**

| POLICY NO. | EFFECTIVE DATE | AGENCY NO. |
|------------|----------------|------------|
| GA 8596100 |                |            |

**Location of all premises owned by, rented to or controlled interest of named insured in such premises (Enter "same" if same as item 1 of declarations): by the named insured "OWNER", "GENERAL LESSEE" OR "TENANT". Part occupied by named insured**

**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) Remuneration | (a) Per 100 sq. ft. of Area | (b) Per 100 sq. ft. of Area | (c) Per $100 of Remuneration | Body Injury | Property Damage |
| 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 | | | | | | | |
| Total Advance Premium | $ | | | | | | |

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)

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