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<br />)~e ' . <br />~ SCOTTSDALE INSURANCE COJMPANT <br />8877 N. Gainey Center Drive, Scottsdale, Arizona 85258 <br />. 1-800-423-7675 (outside Arizona) . <br />COMMON POUCY DECLARATIONS A STOCK COMPANY <br />ITEM 1. Named Insured and Mailing Address <br /> <br />;;::;;;; <br />~ <br />- <br /> <br />~ <br />;;::;;;; <br />- <br /> <br />Polley Number <br />CPS0279401 <br /> <br />. NEW <br /> <br />;;::;;;; <br />- <br />- <br />- <br />;;;;;;;;; <br />;;;;;;;;; <br /> <br />== <br />~ <br /> <br />LA PORTE BAY AREA HERITAGE <br />P.O. BOX 847 <br />LA PORTE, TX 77572 <br /> <br />This insu~nce contract Is with an Insurer not licensed to <br />tr~sact Insurance In Ihls State and Is issued and <br />dehver.ed as a surplus lines coverage pursuanllo the <br />Texas In&urance'slabJlee. The Slate Board of Insurance <br />does nOI.audlt the ftnances or review the solvency of the <br />surplus hnes Insurer providing Ihls coverage, and thIs <br />Insurer Is nol a member of llie property and casually <br />Insurance guaranI)' assoclallon created under Article <br />21.28-C, Insurance Code. ArtIcle 1.14-2, Insurance Code <br />requires paymenl of 4.85 percenl tax on gross premium. ' <br /> <br />;;::;;;; <br />~ <br />;;;;;;;;; <br />..- <br />- <br />;;::;;;; <br />- <br />;;;;;;;;; <br />~ <br />~ <br />- <br />;;;;;;;;;;; <br />~ <br /> <br />Agent Name and Address <br /> <br />TEXAS SPECIALTY UNDERWRITERS, INC. <br />510 TURTLE COVE, STE 200 <br />ROCKWALL, TEXAS 75087 <br /> <br />- <br />~ <br />;;::;;;; <br />- <br /> <br />ITEM 2. Policy Period <br /> <br />From: 05/09/1999 <br /> <br />Agent No. <br />To: 05/09/2000 <br /> <br />42002 <br /> <br />Term: 366 DAYS <br /> <br />- <br />- <br />;;::;;;; <br />= <br />;;;;;;;;; <br />- <br />;;;;;;;;;;; <br />~ <br /> <br />12:01 A.M.. Standard Time at your mailing addre... <br /> <br />Business Description: <br /> <br />MUSEUM <br /> <br />~ <br /> <br />In return for the payment of the premium. and subject to all the terms of this policy, we agree with you to provide the <br />Insurance as stated in this policy. This policy consists of the following coverage parts for which a premium Is Indicated. <br />Where no premium is shown, there Is no coverage. This premium may be subject to adjustment. <br /> <br />Coverage Partes) Premium <br /> <br />Commercial General Liability Coverage Part $ 250 <br /> <br />Commercial Property Coverage Part $ 413 <br /> <br />Commercial Crime Coverage Part $ NOT COVERED <br /> <br />Commercia/Inland Marine Coverage Part $ NOT COVERED <br /> <br />Commercial Auto (Business Auto or Truckers) Coverage Part $ NOT COVERED <br /> <br />Commercial Garage Coverage Part $ NOT COVERED <br /> <br />Profession~1 Liability Coverage Part $ NOT COVERED <br /> <br />$ <br /> <br />$ <br /> <br /> Total Polley Premium: $ 663.00 <br /> POLICY FEE $ 75.00 <br /> STATE TAX $ 35.79 <br />.. STAMPING FEE $ 1.11 <br /> TOTAL $ 774.90 <br />-:: $ <br /> <br />Form(s) and Endorsement(s) made a part of this policy at time of Issue: <br /> <br />See Schedule of Forms and Endorsements <br /> <br />Countersigned: 05/05/1999 By <br />. ALZ (LS CATE AUTHORlZEDREPRESENTATlVE <br />~'S COMMON POLICY DEClARATION AND THE SUPPLEMENTAL DECLARATION (S) , TOGETHER WITH THE COMMON POUCY CONDITIONS, <br />COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS,IF ANY, COMPLETE THE ABOVE NUMBERED POUCY. <br /> <br />OPS.[).1 (8-96) I 111m 1111111111111111111111111111 INSURED 111111111111111111111111111 111111111111111111111111111111111 <br /> <br />c:~ <br /> <br />