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IINSU~D <br />I Pa~sey Lior~ Club <br />I P. IL Box 771- <br /> <br />I RTTN~ 3enT <br /> <br />I <br /> <br />I <br /> <br />I [ ] ~I~ <br />I'[] <br /> <br />I <br />I <br /> <br />CqLISEB Ii:LOSS <br /> <br />III[!CRIPTIffi ill: III~I~TIDlt/~I[L~/PRflODllYiI~I__LelI~ l.I~TlflH) <br />I Glll~Iffi ~ ~ <br />I <br />I <br />I <br /> Ilkl. LIRBILII~/ LIMITS IN <br /> <br />1(2NE~/F0~ II~alltT <br /> <br />I EI~R~I. LIA~ILIIY <br />I [ ] (1)P[l~Ill. IENBtflL LIA~ILIrf <br />I [_1[ ] OJIlHSli~ [ ] ~ <br />I 1~1 (ItEmS & [l)HlitflCl~ PRfllECTI~ <br />i IX] PO~I~ ~ ~ <br /> <br />~- · <br /> <br />I <br />I <br />I <br />I <br />Ii~'TR~ ~TE FOR O_qll~ ~ <br />I / / <br /> <br />IBEIERtl. I:~RE~IE <br />I PRDIXCTS--(II~/I~ I:IGGFEBATE <br />IP'ERSDII~ & RDVERTIS1NB IK,IURY <br />I EI:IDi _ _~COJP, Rglt <br />IFIRE ~ (I:~IY ~ FIRE) <br />IIWEI)ICAL EIPE)EEI~[Y (HE PF.R!~) <br /> <br />$10~ <br /> <br />I~lJlO~)8II.E <br /> LI~ILITY' <br /> [ ] H(W~ <br /> HIRE]) <br /> <br />[ ) SOIEIM~ VBqI~m <br /> <br />ICg. <br /> <br />IBI- PEI~IACCID <br />I1:I) <br />Ili~, <br />IPlP <br />RIM <br /> <br />I [ J[ILLISIOIq i)~: <br />I <br /> <br />[ )OTC <br /> <br />I [ ] AU. VE)IICI.F.~ <br />I C ] ~ ~EHICLES <br /> <br />I [1 ACV <br />I [ ) STRTE0 R~OJ~T <br /> <br />C]~R <br /> <br />IEI(iESS LII~ILITY <br />I [ ] LI,~I~ IA FDRM <br />I [ ) OIl-ER ~ U~FELL~ FORll <br />I <br /> <br />I~AER'S [X)PI:IER~TION I EI~.OYERS~ LIRBILITY <br />1 <br /> <br />I <br />IREIRD DATE FOR [LRII~ Rq~ <br /> <br />I / I <br /> Statutory <br />I EA ~CCIOENT <br /> <br /> lEACH OCCURRENCE <br /> I AGGRE~TE <br /> I SE~-IltSIJREI) REIENII(]H <br /> <br />DI!~I~ I.~ <br /> <br />I)ISF_FISE--EA E)'I:~DYEE <br /> <br />ISP'ECIAL CaI~ITIII'tS/RESTR1CTIOttS/DTIE. R CSVER~_S <br />I <br />I <br />I <br />INIIME RKO l:llDl) RESi; <br /> <br />I <br /> <br />i <br />I [ )HORT [ ]LI:)~ ~YEE [ )RDIL IHS <br />I[) <br />II:I(:IIRD 75-.S (11/~5), , <br /> <br />[ )HDRT [ )LI~ ~YEE [ ]I::K)DL INS <br />[) <br /> <br />ILOA~ NU~.R <br />II1U'~RI ZEI) REPRESE)fl'RTI UE <br /> <br />I 1::8~T~ II~PJR~CE AGENCY <br /> <br /> <br />