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Home My WebLink AboutTIMBERLINE CHURCH - INSURANCE CERTIFICATEQBrotherhood MAN - Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 Ministry First Page 1 of 1 . AGREEMENT In return for the payment of the premium and subject to all the terms of the policy, we agree to provide the insurance stated in the policy. COMMON. POLICY DECLARATIONS NAMED INSURED Policy Number: 05M5A0358236 GROUP 168 TIMBERLINE CHURCH 2908 S TIMBERLINE RD Renewal.of: 05M5A0358236 FORT COLLINS CO 80525 POLICY 1 1 YEAR(S)FROM 07/27/14 TO 07/27/15 12:01 A.M. AT DECLARED PREMISES PERIOD TYPE OF OPERATION: Church only FORM OF ORGANIZATION: CORPORATION This policy consists of the following coverage parts for which a form number is Indicated. FORM NAME FORM NO. FORM NAME FORM NO. BASIC Common Policy Conditions CL100 1.0 Amendatory Endorsement CL300 1.0 FOLIC RMS Intro -Table of Contents CP1 1.0 General Conditions Prop BCP100 3.0 System Equip Breakdown BSEB100 2.2 Commercial Liab Coverage GL100 1.0 BCL301 1.0 BN11A 1.1 CL0182 01 01 • BN6025A-D 3.1 EX0606 1.0 BN6EX 1.0 LOC/BLDG DECLARED PREMISES SCHEDULE 0101 2908 S TIMBERLINE RD FORT COLLINS CO OF 0201 144 S MASON ST FORT COLLINS CO LOCATIONS O401 1136 E STUART ST FORT COLLINS CO 0601 360 CROSSROADS BLVD WINDSOR CO 0701 400 N LINK LN FORT COLLINS CO ANNUAL PREMIUM: $ 72,945 BN1B 1.0 BCL100 1.1 OCCUPANCY CHURCH COFFEE HOUSE OFFICE CHURCH DINING PAYMENT PLAN: MONTHLY Terrorism Premium Charge: $ 3,244.00 - See Notice Form BN-6025-A-D • Including Excess Liability Premium. This premium is COUNTERSIGNED _ tC premium audit provision. IO L DATE AGENCY/AGENTNO. #0598-104 MINISTRY RISK MANAGEMENT LLC MONUMENT CO 866-565-6424 CP1 (03/06) The Home Office Address of Brotherhood Mutual Insurance Co. is P.O. Box 2227, Fort Wayne, IN., 46801-2227 140624 140624 INLAND MARINE SCHEDULE Page 1 of 1 C 0 Policy No. : 05M5A0358236 Issued by : BROTHERHOOD MUTUAL INSURANCE COMPANY Name of Insured : TIMBERLINE CHURCH COMPUTER EQUIPMENT HARDWARE SCHEDULE 1. TOSHIBA PA 5254U A 59693704A 2. IBM 2611-412 412 AA-DHKLT 3. IBM 2611 412 AADFVN6 4. SONY PCG F680 4-650-186-11 SKD 5. TOSHIBA SATELLITE 1800-5203 X1071541PU 6. SONY PCG EX370 28332430-3531019 7. SONY 992L 992L 28332430-3530806 8. COMPAQ PRESARIO 4784 TW01211698 9. SONY PCG GR300K 6CTTAI-35533-M5- 10. IBM THINKPAD A30 78-DL595 11. SONY SUPERSLIM R508 PCGR505GCK 12. SONY GRS 700 A2224MGB 13. SONY VAIO PCG-GRS700K 600215413000006 14. SONY PCG GRZ660 3112766 15. DELL MFG LATITUDE D500 DRV8831 16. SONY PCG ZIR 2.814363032E+014 17. DELL MFG LATITUDE C600 CN09C748481551A 18. COMPAQ CPQR 3030US CND4070GlK 19. DELL MFG INSPIRON 5150 20. SONY VGN-A170P 142621943000001 21. DELL MFG INSPIRION 5150 CN-OW0940-12961- 22. DELL MFG 5150 $500 Deductible Applies $ 1,300.00 1,680.00 1,410.00 2,278.00 1,154.00 1,978.00 1,978.00 450.00 1,885.00 2,362.00 1,900.00 1,670.00 1,670.00 1,600.00 1,436.00 2,200.00 505.00 1,500.00 1,127.00 2,150.00 1,274.00 1,126.00 * * * Schedule Total : $ 34,633.00 * * 140624 Page 1 of 2 INLAND MARINE SCHEDULE Policy No. : 05M5A0358236 Issued by : BROTHERHOOD MUTUAL INSURANCE COMPANY 0 Name of Insured : TIMBERLINE CHURCH MUSICAL INSTR - ALL OTHERS SCHEDULE 1. BASS GUITAR AMP, BRAND: DAVID EDEN, MODEL -METRO, SERIAL #1342 2. ROLAND KEYBOARD, MODEL-RD700, 66 KEY ELECTRIC PIANO, SERIAL 3. BASS GUITAR, MODEL SQUIRE, SERIAL #E1007007 4. ELEC SIX STRING GUITAR, MODEL-STRAT 5. IBANEZ SR900 C04061915 BASS GUITAR 6. CONGAS -MATADOR CUSTOM W/STANDS 7. EXTREME POWERED SPEAKER MN-MPA5500 SN-Blll0077 8. EXTREME COMPANION SPEAKER MN-MP5601 SN-H24949 9. 2 ULTIMATE SPEAKER STANDS MN-TS80B @ $75 EACH 10. 100 FOOT SPEAKER CONNECTING CABLE 11. MACKIE MISER MN-1202-VLZ PRO SN-BU102560 12. FENDER PASSPORT MN-P250 WHOLE SYSTEM SN-N10362000 PN-069-1002 13. 2 ULTIMATE SPEAKER STANDS MN-TS80B @ $75 EACH 14. 1 FENDER MICROPHONE W/XLR CABLE 15. 1 FENDER PASSPORT MN-PD-250 WHOLE SYSTEM SN-GD82806FM 16. 2 FENDER SPEAKER STANDS @ $50 EACH 17. FENDER MICROPHONE W/XLR CABLE IN CASE 18. 4 BELMORE PORTABLE MUSIC STANDS NO SN OR MN @ $65 EACH • 19. 20. WHIRLWIND 24 CHANNEL SNAKE (BLUE) NO MN OR SN RAPCO 12 CHANNEL SNAKE NO MN OR SN 21. PEAVEY BASS AMP MN-300CHS SN-CK250376 22. PEAVEY BASS SPEAKER ENCLOSER MN-210TX SN-00124250/JHA23 23. 2 GREY PLASTIC TUBS MISC CABLES/MICS 2-SHURE CORDED MICS 24. 2 12-XLR CABLES 20 EACH 25. 1 LARGE GREEN PLASTIC TUB -POWER CORDS 2-YELLOW 50' CORDS 26. 2 YAMAHA SPEAKERS (MONITOR TYPE) MN-SM121V SN-07717877 & 27. FENDER GUITAR AMPLIFIER MN -CHAMP 25 PR201 300 SN-LO-319980 28. 2 SOUNDTECH SPEAKERS CX4C MN-SMZ SN-951204121 & 941002749 29. 2 ULTIMATE SPEAKER STANDS SN-282582 & 282600 30. SOUNDTECH AMP MN-PL502 ENCLOSED IN A BLACK TRAVEL CASE 31. PEAVEY AMP MN-PV4C ENCLOSED IN A BLACK TRAVEL CASE 32. PEAVEY AMP MN-PV8.5C ENCLOSED IN A BLACK TRAVEL CASE 33. JVC VHS PLAYER/RECORDER MN-HRS3500U SN024J0786 ENCLOSED IN A 34. TASCAM CD/CASS PLAYER MN-CD-A500 SN-0120716 ENCLOSED IN A 35. 2 ALESIS REVERS UNITS ENCLOSED IN A SKB TRAVEL CASE @ $250 36. ALESIS COMPRESSOR ENCLOSED IN A SKB TRAVEL CASE 37. ALESIS EQ UNIT MN-ME9230 SN-QS1606611 ENCLOSED IN A SKB 38. SOUNDTECH EQ UNIT MN-Q150 ENCLOSED IN A SKB TRAVEL CASE 39. MACKIE MIXER CONSOLE MN-T36459 40. 2 EV LARGE STAGE SPEAKERS (WITH COVERS) MN-1512ER 41. KURZEWIL KEYBOARD W/TRAVEL CASE MN-K2000 SN-4996030SO354 42. ROLAND KEYBOARD (NO CASE) MN-A90EX SN-ZJ96360 $500 Deductible Applies 1,500.00 1,200.00 500.00 1,000.00 600.00 375.00 400.00 300.00 150.00 50.00 200.00 1,100.00 150.00 65.00 1,100.00 100.00 65.00 260.00 300.00 150.00 350.00 200.00 130.00 40.00 230.00 800.00 300.00 900.00 150.00 300.00 400.00 600.00 200.00 200.00 500.00 200.00 150.00 150.00 600.00 1,000.00 1,000.00 750.00 140624 Page 2 of 2 INLAND MARINE SCHEDULE 0 • Policy No. : 05M5A0358236 Issued by : BROTHERHOOD MUTUAL INSURANCE COMPANY Name of Insured : TIMBERLINE CHURCH MUSICAL INSTR - ALL OTHERS SCHEDULE 43. ROLAND PIANO AMP MN-KC500 SN-CP16045 44. ROLAND V-DRUMS CLUB SERIES (ELECTRONIC) MN-TD6 SN-AQ46183 45. YAMAHA CLAVINOVA KEYBOARD MN-CLP123 SN-046858 46. BASS AMP W/ONBOARD MIXER MN-SW65 SN-S011205842 47. AKAI DVD PLAYER (STORED IN CABINET) MN-DVPS760 SN-02040 74364 48. SONY CD PLAYER (STORED IN CABINET) MN-CDP390 SN-867914 49. YELLOW TOOL BOX W/MISC PATCH CABLES, ORANGE 50' POWER CORD, 50. 2-ULTIMATE SPEAKER STANDS MN-TS80B @ $75 EACH 51. MACKIE MISER CONSOLE MN-CR1604 SN-A34942 52. ROLAND 88 KEY BLACK KEYBOARD MODEL RD 700SX S#ZT01521 53. ROLAND 88 KEY BLACK KEYBOARD MODEL RD 700SX SXZT01371 $500 Deductible Applies * * * Schedule Total : $ 500.00 1,100.00 400.00 499.00 200.00 250.00 .00 150.00 700.00 1,450.00 1,450.00 25,414.00 * * 140624 INLAND MARINE SCHEDULE Page 1 of 1 Policy No. : 05M5A0358236 Issued by : BROTH Name of Insured : TIMBERLINE CHURCH PHOTOGRAPHIC EQUIPMENT SCHEDULE 1. 1 CANON XL1 3CCD DIGITAL VIDEO CAMCORDER NTSC (MODEL #2610201783) 2. 1 CANON XL1 3CCD DIGITAL VIDEO CAMCORDER NTSC (MODEL #2720700128) 3. 1 OLYMPUS CAMEDIA E-10 (MODEL #E-10) 4. 1 SONY LCD DATA PROJECTOR (MODEL #VLP-PX20) 5. 1 LIBEC TRIPOD T57 (NO MODEL 3) 6. 1 CHRISTIE LX25 PROJECTOR (MODEL #38VIV208-01 SERIAL #20815626) REPLACEMENT COST $500 Deductible Applies J MUTUAL INSURANCE COMPANY Fj * * * Schedule Total : $ 2,500.00 2,500.00 400.00 2,000.00 500.00 3,000.00 10,900.00 * * A Brotherhood Mutual** Insurance Company Named Insured: TIMBERLINE CHURCH "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 Page 1 of 1 Policy Number: 05M5A0358236 Policy Period: 07/27/14 TO 07/27/15 We provide the Commercial Property coverage at the declared premise(s) for the coverage and limits indicated. The Cov- erages listed herein are provided, subject to the terms of the designated coverage form, and any other applicable forms or endorsements. Property Deductible: $1,000 (Excl. EQ and Opt. Coverages - See Below) Glass Deductible: $250 LV�a LIMIT OF EO VALU- AUTO BLDG TYPE OF PROPERTY INSURANCE COINSURANCE DED ATION [NCR 0101 CHURCH BLDG 26,537,000 AGREED AMT N/A RC 4% 0101 CHURCH PERS PROP 1,782,000 AGREED AMT N/A RC 4% 0101 CHURCH ORD&LAW 1 26,537,000 N/A N/A N/A N/A 0101 CHURCH ORD&LAW 2 300,000 N/A N/A N/A N/A 0101 CHURCH ORD&LAW 3 300,000 N/A N/A N/A N/A 0101 CHURCH PP OTHERS _ 3,000 AGREED AMT N/A RC 0% 0201 COFFEE HOUSE PERS PROP 162,000 AGREED AMT N/A RC 4% 0401 OFFICE PERS PROP 46,000 AGREED AMT N/A RC 0% 0601 CHURCH BLDG 2,752,000 AGREED AMT N/A RC 4% 0601 CHURCH PERS PROP 85,000 AGREED AMT N/A RC 4% 0701 DINING BLDG 993,000 AGREED AMT N/A RC 0% 0701 DINING PERS PROP 52,000 AGREED AMT N/A RC 4% RC=REPL COST PERIL FORM BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 BCP85 3.1 LOC & LIMIT OF DEDUCTIBLE BLDG DESCRIPTION OF COVERAGE INSURANCE AMOUNT FORM NUMBER ALL Employee Dishonesty 100,000 N/A BCP37A 3.0 ALL Theft M & S 81000 $250 BCP36 3.0 ALL Sewer/Drain See Form $1,000 BCP135 2.3 ALL Prop Protect+ See Form $1,000 BCP27A 3.1 ALL Sys Eq Bkdwn $1,000 BSEB100 2.2 ALL Extra Expense 100,000 N/A BCP12 3.1 ALL Interior Dmg See Form $1,000 BCP49 1.2 ALL Terrorism 32,412,000 $1,000 BCL0600 3.0 MORTGAGEES / ADDITIONAL INTERESTS FIRSTBANK ISAOA FIRSTBANK ISAOA LOC 0701 10403 W COLFAX AVE 10403 W COLFAX AVE LAMBDA CHI ALPHA HOUSE CORP LAKEWOOD CO 80215 LAKEWOOD CO 80215 C/O MICHAEL A SMITH MORTGAGEE MORTGAGEE 600 HARRISON ST Loan No.: 8755590 8755620 Loan No.: 8755590 8755620 DENVER CO 80206 • LOSS PAYEE BCP0643 of 08 BCP12G 2.2 BCP138 2.4 BCP500 1.0 BCP88 2.2 BN100 1.0 BN12V 1.0 BN15 1.0 BN27 1.1 CL1630 06 06 CP0171 10 08 CP111 1.0 CP132 1.0 EX0651 2.3 Cp2 2113 140624 "Bear ye one anther's burdens and Brotherhood Mutual- so fulfill the law of ChrisL" Insurance Company Galatians 6:2 INLAND MARINE DECLARATIONS Page 1 of 1 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/14 TO 07/27/15 LV� a LIMIT OF DEDUCTIBLE BLDG DESCRIPTION OF COVERAGE INSURANCE AMOUNT FORM NUMBER ALL IM Comp Hdwre 34,633 $500 BIM7201 1.0 ALL IM Mus Other 25,414 $500 IM1250 01 05 ALL IM Photo Eqp 10,900 $500 IM1350 01 05 ADDITIONAL INTERESTS • 1 OTHER INLAND MARINE FORMS IMD1 (03/06) 140624 Brotherhood Mutual Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 COMMERCIAL LIABILITY DECLARATIONS Page 1 of 1 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5AO358236 Policy Period: 07/27/14 - 07/27/15 The Coverages listed herein are provided subject to the terms of the designated coverage form and any other applicable forms or endorsements. Only one liability coverage and one medical coverage will apply to an occurrence and any related loss. Any limit which is specifically stated within a coverage form or endorsement represents the most we will pay for the coverage to which such limit applies. For application of limits, see Liability and Medical Coverage form (BGL-11). SCHEDULE OF LIMITS POLICY LIMITS GENERAL OCCURRENCE LIMIT ($) GENERAL AGGREGATE LIMIT ($) 1,000,000 3,000,000 PRINCIPAL ( Coverage COVERAGE LIMIT COVERAGE AGGREGATE LIMIT COVERAGES Designation) FORM M W Bodily Injury/Property Damage Liab. (L) GL100 1.0 1,000,000* 3,000,000* Medical Payments (M) GL100 1.0 10,000*per person 3,000,000* Products/Completed Work (N) GL100 1.0 1,000,000* 3,000,000* Fire Legal Liability (0) BGL951 3.0 1,000,000* 3,000,000* ADDITIONAL COVERAGES/INCLUDED FORM COVERAGE LIMIT COVERAGE AGGREGATE LIMIT M rat Church Rel-Charitable/Not For Profit �J COVERAGES/OPTIONAL Counseling Acts Directors & Officers Nonowned Property Damage Sexual Acts (With Screening) Religious Athletic Medical Excess Liability Nonowned/Rented Vehicle NORowned Vehicle Medical Computer Related Liability Ministry Operations Security Operations Liability Traumatic Incident Response Religious Communication Discriminatory Acts Liability Terrorism - Covered Acts Benefits Administration Employment Pract ($5,000 Ded) Defense Reimbursement Wage Reimbursement 0 BGL51 2.2 1,000,000* BGL58R 2.2 1,000,000* FORM BGL63 2.2 BGL81B 1.0 BGL951 3.0 BGL61 3.1 BGL91 2.2 BGL939 2.2 BGL71 2.2 BGL778 2.3 BGL87 2.3 BGL25B 1.0 BGL993 1.0 BGL992 3.0 BGL65 2.2 BGL67 3.0 BGL0250 3.1 BGL83 2.2 BGL85 3.0 BGL89 2.2 BGL99 3.0 3,000,000* 3,000,000* LIMIT COVERAGE (S) 1,000,000* 1,000,000* 1,000,000* 1,000,000* 5,000*Per Person See Form CXL13 1,000,000* 10,000*Per Person 1,000,000* 1,000,000* 1,000,000* See Form BGL992 1,000,000* 1,000,000* 1,000,000* 1,000,000* 1,000,000* See Form BGL89 2,000*Per Person 3,000,000* 3,000,000* 3,000,000* 1,000,000* 3,000,000* See Form CXL13 3,000,000* 3,000,000* 3,000,000* 3,000,000* 3,000,000* See Form BGL992 3,000,000* 3,000,000* 3,000,000* 3,000,000* 3,000,000* See Form BGL89 3,000,000* * Only a single limit applies to the loss. All coverage limits are subject to the general occurrence limit and all aggregate limits are subject to the general aggregate limit. CLD1 (03/07) 140624 Qw- Brotherhood MOW - Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 COMMERCIAL LIABILITY DECLARATIONS Schedule of Additional Information Page 1 of 2 • Policy Number: 05M5A0358236 Policy Period: 07/27/14 - 07/27/15 OTHER LIABILITY AND MEDICAL FORMS BCL966CO 1.0 BGL100A1 2.2 BGLll 2.3 BGL150D 2.2 BGL613 1.0 BGL939AISP 1.0 BN150 1.0 EX0281 2.4 EX909 1.0 EX939ESP 1.0 GLO163 01 08 GL0950 12 99 GL1270 06 06 GL890 1.0 For r nclpa overage of nc u ng Excess a overage ROCKY MOUNTAIN GENERAL CNCL OF THE ASSEMBLIES OF GOD 6295 LEHMAN DR STE 202 COLORADO SPRINGS CO 80918 0 JOHN SAILER & SAILER CONSTRUCTION OF FORT COLLINS 5318 HIGHCASTLE DR FORT COLLINS CO 80525 RELATED ORGANIZATION() OPERATION(S) - For designated Related Coverages. LOC 0201 POUDRE WIGWAM LLC ANNELLE PRISON PROPERTY MGR 620 E ELIZABETH ST FORT COLLINS CO 80524 SCHEDULE OF LIABILITY EXPOSURES In issuing this policy, we have relied on material information provided to us by you. The following schedule discloses all of your insurable exposures known to exist at the policy inception date as conveyed by you. Declared premises must be owned, occupied, or rented by you or your scheduled related organizations. Exposure Classification Code **CHURCH 08101 FOOD & CLOTHING PANTRY 05813 **MISSION CHURCH 08101 PLAYGROUNDS 30320 GROUNDS - EXCESS OF FIVE ACRES 15100 SOFTBALL FIELD RATED AS PLAYGROUND 30320 BLEACHERS OR GRANDSTANDS 30035 COFFEE SHOP 06501 144 S Mason St Fort Collins BOOK/MAGAZINES/STATIONERY STORES - SMALL 05813 RETAIL THRIFT SHOP 05813 THRIFT SHOP 05813 OFFICES - NOC 04504 1136 E Stuart St Fart Collins GOLF CART 15002 OUTREACH MINISTRY 30130 **CHURCH 08101 360 Crossroads Blvd Windsor Rating Basis Co a uan Ity a 115,068 a 2,000 a 2,500 d 1 1 33 d 1 d 1 a 4,800 CO a 2,000 a 1,000 a 1,000 a 5,000 CO d 3 i 1 a 13,342 CO **Including Products / Completed Work Rating asis Code: (a)Are(,fbosPay(; ll (c) Gross Sales -Receipts, (d) Each, (a) Pupils, (f) Teachers, (g) Pastors, (h) Frontage, (1) 0) Cam perdays, k) C CLD2 (03/06) 140624 Brotherhood Mutual" Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ" Galatians 6:2 COMMERCIAL LIABILITY DECLARATIONS Schedule of Additional Information Page 2 of 2 Policy Number: 05M5AO358236 Policy Period: 07/27/14 - 07/27/15 OTHER LIABILITY AND MEDICAL FORMS I ADDITIONAL INSURED(S) - For Principal Coverage of Including Excess Liability overage LOC 020 OUTDOOR AREA CITY OF FORT COLLINS 215 N MASON ST FORT COLLINS CO 80524 RELATED ORGANIZATION(S) OPERATION(S) - For designated Related Coverages. •SCHEDULE OF LIABILITY EXPOSURES In issuing this policy, we have relied on material information provided to us by you. The following schedule discloses all of your insurable exposures known to exist at the policy inception date as conveyed by you. Declared premises must be owned, occupied, or rented by you or your scheduled related organizations. Exposure Classification Code Rating Basis Coe uan Ity **CHURCH 08101 a 7,605 400 N Link Ln Fort Collins CO CONSTRUCTION OPERATIONS - OWNER 37802 k 355,000 FOOD OR DRINK - RETAIL STORES - NOC 83800 c 108,000 BOOKS, MAGAZINES AND STATIONERY STORES 34113 c 50,000 PASTORAL COUNSELING g 17 NON -STUDENT ATHL MED i SPECIAL EVENTS 1 J **Including Products / Completed Work Rating Basis Code: (a) Area, (b) Payroll (c) Gross Sales -Receipts, (d) Each, (a) Pupils, if ) Teachers, (g) Pastore, (h) Frontage, (i) Flat, B) Camper days, (k) Cast, (1) other CLD2 (-oaro6) 140624 Is SCHEDULE - ADDITIONAL COVERED MINISTRIES Policy No.: 05MSA0358236 Issued by: BROTHERHOOD MUTUAL INSURANCE COMPANY Named Insured: TIMBERLINE CHURCH ADDITIONAL COVERED MINISTRIES (OPERATION(S) OF THE NAMED INSURED)* TIMBERLINE HOLDINGS LLC 2908 S TIMBERLINE RD FORT COLLINS CO 80525 0 The operation(s) listed herein are covered as a ministry of the Named Insured, subject to all of the terms of the policy. o separate limit of coverage applies to the listed ministry operation(s). ACM01 (06/12) BROTHERHOOD MUTUAL INSURANCE COMPANY 140624 , "Bear ye one another's burdens and "0% Brotherhood Mutual- so fulfill the law of Christ." I nsure nce Company Galatians 6:2 HIGH HAZARD ACTIVITIES DECLARATIONS Page 1 of 1 • Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/14 - 07/27/15 0 LJ LIMITS APPLICABLE ACTIVITY FORM LIABILITY MEDICAL AGGREGATE LIMIT Skate Park Operations BGL21 3.1 100, 000 per occur 0 per person 300,000 Firework Sales BGL21 3.1 100, 000 per occur 0 per person 300,000 Fireworks Display BGL21 3.1 100,000 per occur 0 per person 300,000 Construction Oversight BGL21 3.1 100, 000 per occur 0 per person 300,000 For details regarding how the above limits will apply, see the How Much We Pay Section of the High Hazard Activities Coverage Limits Form (BGL-21 X CHH1 (03/06) 140624 Brotherhood Mutual Insurance Company 6400 Brotherhood Way a P.O. Box 2227 Fort Wayne, IN 46801-2227 260.482.8668 • AGREEMENT 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 the Excess/Umbrella Liability coverage endorsement. COMMERCIAL EXCESS LIABILITY SUPPLEMENTAL DECLARATIONS Name of Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Location Address: 2908 S TIMBERLINE RD FORT COLLINS CO 80525 Policy Period: From 7/27/14 to 7/27/15 , at 12:01 A.M., standard time at the address shown above. PREMIUM -Subject To Annual Adjustment $ 2,468 LIMIT OF INSURANCE - EXCESS LIABILITY COVERAGE Coverage Limit (per Occurrence): $ 4,000,000 Coverage Aggregate Limit: $ 4,000,000 Deductible/Retention: $ N/A .OPTIONAL COVERAGE INFORMATI N Coverage Included/Excluded Limit Directors & Officers Included $ 4,000,000 Employment Practice Excluded $ Sexual Acts Excluded $ ** Optional Coverage Limits are the same as the Excess Liability 'per Occurrence' and Aggregate limits shown above, unless otherwise specified. SCHEDULE OF UNDERLYING INSURANCE Type of Policy Policy Limits of Insurance Insurer Period Number Liability General BROTHERHOOD MUTUAL 7/27/14 to 05M5A0358236 1,000,000 OCC/ Liability INSURANCE COMPANY 7/27/15 3,000,000 AGG Automobile BROTHERHOOD MUTUAL See Applicable 05A5A0358237 Liability INSURANCE COMPANY Declaration Page Employers BROTHERHOOD MUTUAL See Applicable 05WSA0358238 Liability INSURANCE COMPANY Declaration Page • 1,000,000 CSL 1001000/5001000/ 100,000 CXL-13 (2.1)