PI-CXL-002 (04/13)

POLICY NUMBER: PHUB510368

COMMERCIAL UMBRELLA LIABILITY INSURANCE

POLICY DECLARATIONS

Philadelphia Indemnity Insurance Company

120975
Asset Insurance LLC
PO Box 2314
Colorado City, AZ 86021
(888)430-2790

NAMED INSURED:

Masada Charter School, Inc.

MAILING ADDRESS: PO Box 2277

Colorado City, AZ 86021-2277
08/21/2015
POLICY PERIOD: FROM
TO
TIME AT YOUR MAILING ADDRESS SHOWN ABOVE

08/21/2016

AT 12:01 A.M. STANDARD

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.
LIMITS OF INSURANCE
EACH OCCURRENCE LIMIT
(LIABILITY COVERAGE)

1,000,000

PERSONAL & ADVERTISING INJURY LIMIT

1,000,000

Any one person or organization

PRODUCTS COMPLETED OPERATIONS AGGREGATE LIMIT

1,000,000

GENERAL AGGREGATE LIMIT (LIABILITY COVERAGE) (except with

respect to Auto Liability and Products Completed Operations)

1,000,000

RETAINED LIMIT:

RETAINED LIMIT
10,000
$_________________________

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PI-CXL-002 (04/13)
POLICY NUMBER: PHUB510368

PREMIUM
PREMIUM SUBTOTAL
STATE TAXES, FEES, SURCHARGES (if applicable)
PREMIUM TOTAL (including Taxes, Fees, Surcharges)
AUDIT PERIOD:

X NOT APPLICABLE

ANNUALLY

804.00
$
$Not Applicable
804.00
$

SEMI-ANNUALLY

QUARTERLY

MONTHLY

DESCRIPTION OF BUSINESS

FORM OF BUSINESS:

NON PROFIT ORGANIZATION

________________________________________________________________

BUSINESS DESCRIPTION:

Specialty School Umbrella

ENDORSEMENTS ATTACHED TO THIS POLICY

SEE ATTACHED SCHEDULE

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PI-CXL-002 (04/13)
POLICY NUMBER: PHUB510368
SCHEDULE OF UNDERLYING INSURANCE
Employers' Liability
Company:
Policy Number:
Policy Period:
Minimum Applicable Limits
Bodily injury by accident
Bodily injury by disease
Bodily injury by disease

$
Each Accident
$
Each Employee
$ _____________________ Policy Limit

X Occurrence
Commercial General Liability
Philadelphia Indemnity Insurance Company
Company:
Policy Number:
08/21/2015
08/21/2016
Policy Period:
Not Applicable
Retroactive Date: _________________

Minimum Applicable Limits:

General Aggregate
Products-Completed Operations Aggregate
Personal And Advertising Injury
Each Occurrence

$
$
$
$

Commercial Auto Liability

Company:
Policy Number:
Policy Period:
Minimum Applicable Limits
Garage Aggregate Limit For Other Than Autos
(if applicable)
Each Accident

$
$

3,000,000
3,000,000
1,000,000
1,000,000

Professional Liability
Occurrence
Philadelphia Indemnity Insurance Company
Company:
Policy Number:
08/21/2015
08/21/2016
Policy Period:
08/21/2006
Retroactive Date: _________________
Minimum Applicable Limits
Each Professional Incident
Aggregate

$
$

Claims-Made

X Claims-Made

1,000,000
1,000,000

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PI-CXL-002 (04/13)
POLICY NUMBER: PHUB510368
Employee Benefits Liability
Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits

Occurrence

Claims-Made

Occurrence

Claims-Made

Occurrence

Claims-Made

Occurrence

Claims-Made

$
$
Abuse or Molestation
Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits
$
$
Directors & Officers Liability
Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits
$
$
Liquor Liability
Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits
$
$

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PI-CXL-002 (04/13)
POLICY NUMBER: PHUB510368
Watercraft Liability
Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits

Occurrence

Claims-Made

$
$
Other Coverages Not Included in Above

Occurrence

Claims-Made

Company:
Policy Number:
Policy Period:
Retroactive Date: _________________
Minimum Applicable Limits
$
$

THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE
FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY.
Countersigned:

By:
(Date)

(Authorized Representative)

IN WITNESS WHEREOF, we have caused this policy to be executed and attested, and, if
required by state law, this policy shall not be valid unless countersigned by our authorized
representative.

President

Secretary

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