Sample Policy - Attune Insurance

POLICY NUMBER: DEMO0001-00000-01 PREVIOUS POLICY NUMBER:

HU DS 05 01 18

COMMON POLICY DECLARATIONS

Named Insured:

Demo - Retail

Named Insured's Mailing Address: 3106 North College Avenue Fayetteville AR 72703

S Producer Name and Address:

a Producer Code: CASURA0001

Policy Period: From: 05/28/2019 To: 05/28/2020 AT 12:01 A.M. STANDARD TIME AT YOUR MAILING

m ADDRESS

Business Description:

p IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF

THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.

le THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM

P BUSINESSOWNERS COVERAGE PART

$ 741.00

o COMMERCIAL INLAND MARINE COVERAGE PART

$

l OTHER

$

icy$

TRIA PREMIUM

$ 7.00

TAXES AND SURCHARGES, if any

$ 0.00

TOTAL

$ 748.00

MINIMUM PREMIUM PAYABLE AT INCEPTION

$

HU DS 05 01 18

Includes copyrighted material of Insurance Services Office, Inc. with its permission. ? 2018 Blackboard U.S. Holdings, Inc. All

Rights Reserved. May not be copied without permission.

Page 1 of 2

Schedule Of Forms And Endorsements Attached As Part Of This Policy:

BP 05 17 01 06 Exclusion - Silica Or Silica-Related Dust

BP 01 53 07 11 Arkansas Changes

BP 04 93 01 06 Total Pollution Exclusion With A Building Heating Equipment Exception And A Hostile

Fire Exception

BP 05 77 01 06 Fungi Or Bacteria Exclusion (Liability)

HU N 104 04 18 Policyholder Disclosure Notice Of Terrorism Insurance Coverage (Coverage Included)

HU 01 05 01 18 Service Of Suit

BP 04 17 01 10 Employment-Related Practices Exclusion

SM 21 02 01 18 Asbestos Exclusion

SM 04 01 01 18 BUSINESSOWNERS ENHANCEMENT

HU DS 06 01 18 Signature Endorsement

SM 10 12 01 18 ALUMINUM WIRING EXCLUSION

BP 05 23 01 15 SM 05 53 01 18 IL P 001 01 04

S IL N 016 09 03

HU DS 13 01 18 HU DS 05 01 18

a HU 01 06 01 18

SM 14 01 01 18

m SM DS 01 01 18

BP 00 03 07 13 BP 05 01 07 02 BP P 004 01 07

Cap On Losses From Certified Acts Of Terrorism Data Response and Cyber Liability Coverage Endorsement (AR) U.S. Treasury Department's Office Of Foreign Assets Control ("Ofac") Advisory Notice To Policyholders Arkansas Fraud Statement Common Policy Declarations - Schedule Common Policy Declarations Policyholder Notice Hired Auto And Non-Owned Auto Liability Insurance Businessowners Policy Declarations Businessowners Coverage Form Calculation Of Premium Exclusion Of Loss Due To Virus Or Bacteria Advisory Notice To Policyholders

pl THESE DECLARATIONS, TOGETHER WITH THE ATTACHED SIGNATURE ENDORSEMENT, e SCHEDULE OF FORMS AND ENDORSEMENTS, AND ANY FORMS AND ENDORSEMENTS THAT

WE MAY LATER ATTACH TO REFLECT CHANGES, MAKE UP AND COMPLETE THE ABOVE

Policy NUMBERED POLICY.

HU DS 05 01 18

Includes copyrighted material of Insurance Services Office, Inc. with its permission. ? 2018 Blackboard U.S. Holdings, Inc. All

Rights Reserved. May not be copied without permission.

Page 2 of 2

POLICY NUMBER: DEMO0001-00000-01 PREVIOUS POLICY NUMBER:

HU DS 13 01 18

COMMON POLICY DECLARATIONS - SCHEDULE

Important Notices:

Sa Taxes:

State

mp Fees: le State

Description

Taxable Premium

Taxable Fee

Tax Basis

Rate (%) Total Taxes

Tax $ 0.00

Fee

Taxable

Amount

(Yes/No)

Total Fees

$ 0.00

P THESE DECLARATIONS, TOGETHER WITH THE ATTACHED SIGNATURE ENDORSEMENT,

SCHEDULE OF FORMS AND ENDORSEMENTS, AND ANY FORMS AND ENDORSEMENTS THAT

o WE MAY LATER ATTACH TO REFLECT CHANGES, MAKE UP AND COMPLETE THE ABOVE licy NUMBERED POLICY.

HU DS 13 01 18

Includes copyrighted material of Insurance Services Office, Inc. with its permission. ? 2018 Blackboard U.S. Holdings, Inc.

All Rights Reserved. May not be copied without permission.

Page 1 of 1

Administration Office: 120 Broadway, 17th floor, New York, New York 10271 Phone: 877.200.4872

Statutory Office: 1209 Orange Street, Wilmington, DE 19801

`

POLICY NUMBER: NAMED INSURED:

DEMO0001-00000-01 Demo - Retail

HU DS 06 01 18

SIGNATURE ENDORSEMENT

S Authorization: In Witness Whereof, The Company issuing this policy has caused this policy to be signed

by its authorized officers, but this policy shall not be valid unless countersigned by an authorized representative of the Company, where required.

amBLACKBOARD INSURANCE COMPANY

pl ______________________ e Secretary

_____________________ President

Poli THIS SIGNATURE ENDORSEMENT, TOGETHER WITH THE DECLARATIONS, COMMON POLICY c CONDITIONS, COVERAGE FORM(S), AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE y NUMBERED POLICY.

HU DS 06 01 18

Includes copyrighted material of Insurance Services Office, Inc. with its permission. ? 2018 Blackboard U.S. Holdings, Inc. All Rights Reserved. May not be copied without permission.

Page 1 of 1

Administration Office: 120 Broadway, 17th floor, New York, New York 10271 Phone: 877.200.4872

Statutory Office: 1209 Orange Street, Wilmington, DE 19801

HU 01 05 01 18

SERVICE OF SUIT

This endorsement modifies insurance provided under the following:

S COMMERCIAL PROPERTY COVERAGE PART

COMMERCIAL GENERAL LIABILITY COVERAGE PART

a COMMERCIAL INLAND COVERAGE PART

BUSINESSOWNERS COVERAGE FORM

mp Pursuant to any statute of any state, territory or district of the United States which makes provision therefore we

hereby designate the Commissioner, Superintendent or Director of Insurance or other officer specified for that purpose in the statute, and his successor or successors in office, as our true and lawful attorney upon whom may

l be served any lawful process in any action, suit, contract of insurance and hereby designate the Corporate e Secretary of Blackboard Insurance Company, 1209 Orange Street, Wilmington, DE 19801, as the entity to whom Policy said officer is authorized to mail such process or a true copy thereof.

HU 01 05 01 18

Includes copyrighted material of Insurance Services Office, Inc. with its permission. ? 2018 Blackboard U.S. Holdings, Inc. All

Rights Reserved. May not be copied without permission.

Page 1 of 1

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