HomeMy WebLinkAboutInsurance ContractCOMMON POLICY DECLARATIONS
ACCEPTANCE INDEMNITY INSURANCE COMPANY
P.O. BOX 3328
Policy Number: CP00113190 OMAHA, NE 68103 Renewal of Number: CP00108253
Named Insured and Mailing Address
SLAMBANGO, INC.
DBA: MAD HATTERS
317 UNIVERSITY DRIVE W.
COLLEGE STATION TX 77840
Agency and Mailing Address Agency Code: 00314
Western Security Surplus
Insurance Brokers
6504 International Pkwy., Suite 1100
Plano
TX 75093
Policy Period: From 07/30/2010 to 07/30/2011
12:01 A.M. Standard Time at your mailing address shown above.
Business Description: BAR
This insurance contract is with an insurer
not licensed to transact insurance in this
state and is issued and delivered as
surplus line coverage under the Texas
insurance statutes. The Texas Department
of Insurance does not audit the finances or
review the solvency of the surplus lines
insurer providing this coverage, and the
insurer is not a member of the property
and casualty insurance guaranty
association created under Chapter 462,
Insurance Code. Chapter 225, Insurance
Code, requires payment of a 4.85 percent
tax on gross premium.
Tax State: TX
IN RETURN FOR 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.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
Other Charges:
BROKER FEE
STATE TAX
STAMP FEE
$ 300.00
587.87
7.27
TOTAL ADVANCE PREMIUM $ 11, 821.00
TOTAL OTHER CHARGES $ 895.14
TOTAL $ 12,716.14
Form(s) and Endorsement(s) made a part of this policy at time of issue *:
See SCHEDULE OF FORMS AND ENDORSEMENTS - CO 10 10
*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations.
TEXAS HOSPITALITY PROFILE #526 NO FLAT CANCELLATION
25 % MINIMUM EARNED PREMIUM
Countersigned: Plano, TX
08117/2010 JDW -CN Countersigned By Authorized Representative
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S)
AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY.
CO 00 10 12 07 INSURED
PREMIUM
Commercial General Liability Coverage Part
$
5,809.00
Commercial Property Coverage Part
$
120.00
Liquor Liability Coverage Part
$
5,883.00
Equipment Breakdown Coverage
$
9.00
Other Charges:
BROKER FEE
STATE TAX
STAMP FEE
$ 300.00
587.87
7.27
TOTAL ADVANCE PREMIUM $ 11, 821.00
TOTAL OTHER CHARGES $ 895.14
TOTAL $ 12,716.14
Form(s) and Endorsement(s) made a part of this policy at time of issue *:
See SCHEDULE OF FORMS AND ENDORSEMENTS - CO 10 10
*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations.
TEXAS HOSPITALITY PROFILE #526 NO FLAT CANCELLATION
25 % MINIMUM EARNED PREMIUM
Countersigned: Plano, TX
08117/2010 JDW -CN Countersigned By Authorized Representative
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S)
AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY.
CO 00 10 12 07 INSURED
COMMERCIAL GENERAL LIABILITY COVERAGE PART
POLICY NUMBER: CP00113190 DECLARATIONS
❑ Extension of Declarations is attached. FffPCtiva nata- n7 /3n /9(19n 19•n1 n nA Ctgnrinrrl Time
LIMITS OF INSURANCE
General Aggregate Limit (Other Than Products /Completed Operations) $ 2,000,000
Products /Completed Operations Aggregate Limit $ 11000,000
Personal and Advertising Injury Limit $ 1,000,000 Any one person or organization
Each Occurrence Limit $ 11000,000
Damage To Premises Rented To You Limit $ 10o, oo0 Anyone premises
Medical Expense Limit $ Excluded Any one person
RETROACTIVE DATE CG 00 02 only
This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" which occurs
before the retroactive date, if any, shown here: (Enter Date or "None" if no Retroactive Date applies)
BUSINESS DESCRIPTION AND LOCATION OF PREMISES
Form of Business: ❑ Individual ❑ Partnership ❑ Joint Venture ❑ Trust ❑ Limited Liability Company (LLC)
® Organization, including a Corporation (but not including a Partnership, Joint Venture or LLC)
Business Description: BAR
Location of Primary Premises You Own, Rent or Occupy:
317 UNIVERSITY DRIVE W.
COLLEGE STATION TX 77840
CLASSIFICATION AND PREMIUM
Code No. Classification
*
Premium Basis
Rate
Advance Premium
Prem/O s Pr /Co
16930 Restaurants - with sale of alcoholic
s
900,000
6.150
5,532
beverages that are 75% or more of total
Included
Included
annual receipts of the restaurants - without
dance floor: table service
ASSAULT & BATTERY
Flat
277
PER FORM AL1548
Included
Included
Total Coverage Part Advance Premium
$ 5,809
FORMS AND ENDORSEMENTS other than applicable Forms and Endorsements shown elsewhere in the polic
Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue:
See SCHEDULE OF FORMS AND ENDORSEMENTS - CO 10 10
* PREMIUM BASIS TYPE LEGEND
a = Area (per 1,000 sq. ft. of area) c = Total Cost (per $1,000 of Total Cost) m = Admissions (per 1,000 Admissions)
p =Payroll (per $1,000 of Payroll) s = Gross Sales (per $1,000 of Gross Sales) t = See Classification u =Units (per unit)
+ = Products /Completed Operations are subject to the General Aggregate Limit
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
AL 00 01 09 08 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, ISO Properties, Inc., 2000