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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