The URL can be used to link to this page

Home My WebLink AboutTIMBERLINE CHURCH - INSURANCE CERTIFICATE (4),n h, Brotherhood Mutual- In,urance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 MinistryFirst 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 YEAR(S) FROM 07/27/15 TO 07/27/16 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 M Common Policy Conditions CL100 1.0 Amendatory Endorsement :1 Intro -Table of Contents CP1 1.0 General Conditions Prop System Equip Breakdown BSEB100 4.0 Commercial Liab Coverage BCL301 1.0 BN11A 1.1 CLO182 01 01 BN1B 1.0 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 ANNUAL PREMIUM: $ 70,908 * FORM NO. CL300 1.0 BCP100 4.0 GL100 1.0 BCL100 1.1 OCCUPANCY Church Coffee House Office Church PAYMENT PLAN: MONTHLY Terrorism Premium Charge: $ 3,292.00 - See Notice Form BN-6025-A-D * Including Excess Liability Premium. This premium is sub' u t e to premium audit provision. COUNTERSIGNED ` DATE (1R RF � N _... AGENCY/AGENT NO. #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 150626 Brotherhood Mutual •Insurance Company AGREEMENT 6400 Brotherhood Way • P.O. Box 2227 Fort Wayne, IN 46801-2227 260.482.8668 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: 05M5AO358236 Location Address: 2908 S Timberline Rd Fort Collins CO 80525 Policy Period: From 7/27/15 to 7/27/16 , at 12:01 A.M., standard time at the address shown above. PREMIUM -Subject To Annual Adjustment $ 2,463 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 INFORMATION 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 7/27/15 to OSM5A0358236 1,000,000 OCC/ Liability INSURANCE COMPANY 7/27/16 3,000,000 AGG Automobile BROTHERHOOD MUTUAL See Applicable 05A5AO358237 Liability INSURANCE COMPANY Declaration Page Employers BROTHERHOOD MUTUAL See Applicable 05W5AO358238 Liability INSURANCE COMPANY Declaration Page 1,000,000 CSL 100,000/500,000/ 100,000 CXL-13 (2.1) 150626 Page 1 of 1 INLAND MARINE SCHEDULE Policy No. : 05MSA0358236 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 TWO1211698 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 * * 150626 Page 1 of 2 INLAND MARINE SCHEDULE Policy No. : 05M5A0358236 Issued by : BROTHERHOOD MUTUAL INSURANCE COMPANY 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 CO4061915 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. WHIRLWIND 24 CHANNEL SNAKE (BLUE) NO MN OR SN 20. 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 REVERB UNITS ENCLOSED IN A SKB TRAVEL CASE @ $250 36. ALESIS COMPRESSOR ENCLOSED IN A SKB TRAVEL CASE 37. ALESIS EQ UNIT MN-MEQ230 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 61 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 150626 Page 2 of 2 n INLAND MARINE SCHEDULE 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 * * * Schedule Total : $ $500 Deductible Applies 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 * * 150626 Page 1 of 1 I INLAND MARINE SCHEDULE Policy No. : 05M5A0358236 Issued by : BROTHERHOOD MUTUAL INSURANCE COMPANY Name of Insured : TIMBERLINE CHURCH PHOTOGRAPHIC EQUIPMENT SCHEDULE 1. 1 CANON XL1 3CCD DIGITAL VIDEO CAMCORDER NTSC (MODEL #26102017 $ 83) 2. 1 CANON XL1 3CCD DIGITAL VIDEO CAMCORDER NTSC (MODEL #27207001 28) 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 * * * Schedule Total : $ $500 Deductible Applies 2,500.00 2,500.00 400.00 2,000.00 500.00 3,000.00 10,900.00 * * "Bear ye one another's burdens and Brotherhood Mutual- so fulfill the law of Christ." Insurance Company Galatians6:2 COMMERCIAL PROPERTY DECLARATIONS Page 1 of 2 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/15 TO 07/27/16 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: $1,000 SCHEDULE OF BUILDINGS AND PERSONAL PROPERTY LOC & LIMIT OF EO VALU- AUTO BLDG TYPE OF PROPERTY INSURANCE COINSURANCE DED ATION INCR PERIL FORM 0101: Church BLDG 26,861,000 AGREED AMT N/A RC 4% BCP85 4.0 0101 Church PERS PROP 1,853,300 AGREED AMT N/A RC 0% BCP85 4.0 0101 Church ORD&LAW 1 26,861,000 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% BCP85 4.0 0201 Coffee House PERS PROP 168,500 AGREED AMT N/A RC 0% BCP85 4.0 0401 Office PERS PROP 46,000 AGREED AMT N/A RC 0% BCP85 4.0 0601: Church BLDG 2,774,000 AGREED AMT N/A RC 4% BCP85 4.0 0601 Church PERS PROP 88,400 AGREED AMT N/A RC 0% BCP85 4.0 :ROOF COSMETIC DAMAGE EXCL RC=REPL COST SCHEDULE OF OPTIONAL COVERAGES LOC & LIMIT OF DEDUCTIBLE BLDG DESCRIPTION OF COVERAGE INSURANCE AMOUNT FORM NUMBER ALL Ord & Law A 350,000 $1,000 BCP138B 1.0 ALL Ord & Law B 100,000 $1,000 BCP138B 1.0 ALL Ord & Law C 100,000 $1,000 BCP138B 1.0 ALL Theft Bld Mat 5,000 $250 BCP36 4.0 ALL PersDishonest 100,000 N/A BCP37A 4.0 ALL Theft M & S 10,000 $250 BCP36 4.0 ALL Sewer/Drain See Form $1,000 BCP135 4.0 ALL Water Damage 10,000 $1,000 BCP27 4.0 ALL Sys Eq Bkdwn $1,000 BSEB100 4.0 MORTGAGEES / ADDITIONAL INTERESTS BUILDING#: 01,01 BUILDING#: 06,01 FIRSTBANK ISAOA FIRSTBANK ISAOA 10403 W COLFAX AVE 10403 W COLFAX AVE LAKEWOOD CO 80215 LAKEWOOD CO 80215 MORTGAGEE MORTGAGEE ,oan No.: 8755590 8755620 Loan No.: 8755590 8755620 FORMSOTHER PROPERTY BCP0643 01 08 BCP138 4.0 BCP500 4.0 BCP88 4.0 BN100 1.0 BN12V 1.0 BN15 1.0 BN2567 1.0 CL1630 06 06 CP0171 10 08 CP111 1.0 EX0651 2.3 EX910 1.0 Cp2 2/13 150626 Brotherhood Mut N" Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 COMMERCIAL PROPERTY DECLARATIONS Page 2 of 2 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/15 TO 07/27/16 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: $1,000 SCHEDULE OF BUILDINGS AND PERSONAL PROPERTY LOC & LIMIT OF EQ VALU- AUTO BLDG TYPE OF PROPERTY INSURANCE COINSURANCE DED ATION INCR PERIL FORM SCHEDULE OF OPTIONAL COVERAGES LOC & LIMIT OF DEDUCTIBLE BLDG DESCRIPTION OF COVERAGE INSURANCE AMOUNT FORM NUMBER ALL Extra Exp 100,000 N/A BCP71 1.0 ALL Earnings/Exp 25,000 N/A BCP71 1.0 ALL Rented PPO 10,000 $1,000 BCP12 4.0 ALL Interior Dmg 31,794,200 $1,000 BCP49 4.0 ALL Terrorism 31,794,200 $1,000 BCL0600 3.0 MORTGAGEES / ADDITIONAL INTERESTS OTHE PROPERTY FORMS cp22/I3 150626 "Bear ye one another's burdens and h� Brotherhood Mutual w so fulfill the law of Christ." Insurance company Galatians6:2 Page 1 of 1 INLAND MARINE DECLARATIONS Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/15 TO 07/27/16 INLAND MARINE COVERAGES LOC & LIMIT OF DEDUCTIBLE BLDG DESCRIPTION OF COVERAGE INSURANCE AMOUNT FORM NUMBER ALL IM Comp Hdwre 34,633 $500 BIM7201 4.0 ALL IM Mus Other 25,414 $500 IM1250 01 05 ALL IM Photo Eqp 10,900 $500 IM1350 01 05 ADDITIONAL INTERESTS IMD1 (031'06) 150626 Brotherhood Mutual Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 COMMERCIAL LIABILITY DECLARATIONS Page 1 of 1 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/15 - 07/27/16 The Coverages listed herein are provided subject to the terms of the designated coverage form and any other applicable forms or endorsements. Only one liability coverage and one medical coverage will apply to an occurrence and any related loss. Any limit which is specifically stated within a coverage form or endorsement represents the most we will pay for the coverage to which such limit applies. For application of limits, see Liability and Medical Coverage form (BGL-11). SCHEDULE OF LIMITS POLICY LIMITS GENERAL OCCURRENCE LIMIT ($) GENERAL AGGREGATE LIMIT ($) 1,000,000 3,000,000 PRINCIPAL ( Coverage COVERAGE LIMIT COVERAGE AGGREGATE LIMIT COVERAGES Designation) FORM ($) ($) Bodily Injury/Property Damage Liab. (L) GL100 1.0 1,000,000* 3,000,000* Medical Payments (M) GL100 1.0 10,000*per person 3,000,000* Products/Completed Work (N) GL100 1.0 1,000,000* 3, 000, 000* Fire Legal Liability (0) BGL951 3.0 1,000,000* 3,000,000* ADDITIONAL COVERAGES/INCLUDED FORM COVERAGE LIMIT COVERAGE AGGREGATE LIMIT Church BGL51 4.0 1,000,000* 3,000,000* Rel-Charitable/Not For Profit BGL58R 4.0 1,000,000* 3,000,000* ADDITIONAL COVERAGES/OPTIONAL FORM COVERAGE LIMIT COVERAGE AGGREGATE LIMIT ($) ($) Media Liability BGL41 1.0 1,000,000* 3,000,000* Counseling Acts BGL63 4.0 1,000,000* 3,000,000* Directors & Officers BGL81B 4.0 1,000,000* 3,000,000* Nonowned Property Damage BGL951 3.0 1,000,000* 3,000,000* Sexual Acts (With Screening) BGL61 4.0 1,000,000* 1,000,000* Religious Athletic Medical BGL91 4.0 5,000*Per Person 3,000,000* Excess Liability BGL939 4.0 See Form CXL13 See Form CXL13 Nonowned/Rented Vehicle BGL71 4.0 1,000,000* 3,000,000* Nonowned Vehicle Medical BGL778 4.0 10,000*Per Person 3,000,000* Cyber Liability BGL87 4.0 1,000,000* 3,000,000* Disaster Relief BGL994 1.0 1,000,000* 3,000,000* Security Operations Liability BGL993 4.0 1,000,000* 1,000,000* Worldwide Liability Extension BGL111T 1.1 See Form BGL111T See Form BGL111T Traumatic Incident Response BGL991B 4.0 See Form BGL991B See Form BGL991B Religious Freedom BGL66 1.0 1,000,000* 3,000,000* Terrorism - Covered Acts BGL0250 3.1 1,000,000* 3,000,000* Benefits Administration BGL83 4.0 1,000,000* 3,000,000* Employment Practices BGL85 4.0 1,000,000* 3,000,000* Defense Reimbursement BGL89 4.0 See Form BGL89 See Form BGL89 Wage Reimbursement BGL99 4.0 3,500*Per Person 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. 150626 CLD1 (03/07) Brotherhood Mutual I nsuranre Cum pony "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 3 Policy Number: 05M5A0358236 Policy Period: 07/27/15 - 07/27/16 OTHER LIABILITY AND MEDICAL FORMS BCL966CO 1.0 BGL100A1 2.2 BGLll 4.0 BGL150D 2.2 BGL152 1.0 BGL59RA 4.0 BGL613 1.0 BGL939AISP 1.0 BN150 1.0 EX0281 2.4 EX909 1.0 EX939ESP 4.0 GLO163 01 08 GL0950 12 99 GL1270 06 06 GL890 1.0 For Principal Coverage L. (Not including Excess Liability overage) ROCKY MOUNTAIN GENERAL CNCL OF LOC 0601 LOC 0201 THE ASSEMBLIES OF GOD JOHN SAILER & SAILER POUDRE WIGWAM LLC ANNELLE 6295 LHEMAN DRIVE, STE 202 CONSTRUCTION OF FORT COLLINS FRISON PROPERTY MGR COLORADO SPRINGS CO 80918 5318 HIGHCASTLE DR 620 E ELIZABETH ST FORT COLLINS CO 80525 FORT COLLINS CO 80524 RELATED ORGANIZATION(S) / OPERATION(S) - For designated Related Coverages. Rel-Charitable/Not For Profit TIMBERLINE HOLDINGS LLC 2908 S TIMBERLINE RD FORT COLLINS CO 80525 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 Code uantlty PLAYGROUNDS 30320 d 1 2908 S Timberline Rd Fort Collins CO GROUNDS - EXCESS OF FIVE ACRES 15100 1 33 2908 S Timberline Rd Fort Collins CO SOFTBALL FIELD RATED AS PLAYGROUND 30320 d 1 2908 S Timberline Rd Fort Collins CO BLEACHERS OR GRANDSTANDS 30035 d 1 2908 S Timberline Rd Fort Collins CO GOLF CART 15002 d 3 2908 S Timberline Rd Fort Collins CO OUTREACH MINISTRY 30130 i 1 2908 S Timberline Rd Fort Collins CO **CHURCH 08101 a 119,868 2908 S Timberline Rd Fort Collins CO FOOD & CLOTHING PANTRY 05813 a 2,000 2908 S Timberline Rd Fort Collins CO **MISSION CHURCH 08101 a 2,500 2908 S Timberline Rd Fort Collins CO BOOK/MAGAZINES/STATIONERY STORES - SMALL 05813 a 2,000 RETAIL **Including Products / Completed Work Rating Basis Code: (a) Area, f ) Payroll (c) Gross Sales -Receipts, (d) Each, (e) Pupils, (f ) Teachers, (g) Pastors, (h) Frontage, (i) Flat, 6) Camper days, (k) Cost, (1) 6ther CLD2 (03/06) 150626 "Bear ye one another's burdens and Brotherhood WWI- so fulfill the law of Christ." Insurance Company Galatians6:2 COMMERCIAL LIABILITY DECLARATIONS Schedule of Additional Information Page 2 of 3 Policy Number: 05M5A0358236 Policy Period: 07/27/15 - 07/27/16 OTHER LIABILITY AND MEDICAL FORMS AL INSURED(S) - For Principal Coverage L. (Not including Excess Liability overage) LOC 02 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 Co e uantlty 2908 S Timberline Rd Fort Collins CO THRIFT SHOP 05813 a 1,000 2908 S Timberline Rd Fort Collins CO COFFEE SHOP 06501 a 4,800 144 S Mason St Fort Collins CO THRIFT SHOP 05813 a 1,000 144 S Mason St Fort Collins CO OFFICES - NOC 04504 a 51000 1136 E Stuart St Fort Collins CO **CHURCH 08101 a 13,342 360 Crossroads Blvd Windsor CO FOOD OR DRINK - RETAIL STORES - NOC 83800 c 108,000 2908 S Timberline Rd Fort Collins CO BOOKS, MAGAZINES AND STATIONERY STORES 34113 c 50,000 360 Crossroads Blvd Windsor CO PASTORAL COUNSELING g 17 NON -STUDENT ATHL MED i SPECIAL EVENTS **Including Products / Completed Work Rating Basis Code: (a) Area, ( ) Payroll, (c) Gross Sales -Receipts, (d) Each, (e) Pupils, (f) Teachers, (g) Pastors, (h) Frontage, (i) Flat, 6) Camper days, (k) Cost, (1) Other CLD2 (-03/06) 150626 "Bear ye one another's burdens and Brotherhood Mutual so fulfill the law of Christ." In,uranre Company Galatians6:2 COMMERCIAL LIABILITY DECLARATIONS Schedule of Additional Information Page 3 of 3 Policy Number: 05M5A0358236 Policy Period: 07/27/15 — 07/27/16 OTHER LIABILITY AND MEDICAL FORMS I ADDITIONAL INSURED( - For Principal Coverage L. ( of including Excess Liability overage) 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 Co ecT7uantlty Rating Basis Code: (a) Area, �) Payroll (c) Gross Sales -Receipts, (d) Each, (e) Pupils, (f) Teachers, (g) Pastors, (h) Frontage, (i) Flat, 0) Camper days, (k) ost, (1) other CLD2 (03/06) 150626 Brotherhood WWI - Insurance Company "Bear ye one another's burdens and so fulfill the law of Christ." Galatians 6:2 HIGH HAZARD ACTIVITIES DECLARATIONS page 1 of 1 Named Insured: TIMBERLINE CHURCH Policy Number: 05M5A0358236 Policy Period: 07/27/15 — 07/27/16 LIMITS APPLICABLE ACTIVITY FORM LIABILITY MEDICAL AGGREGATE LIMIT Skate Park Operations BGL21 4.0 100, 000 per occur 0 per person 300,000 Firework Sales BGL21 4.0 100,000 per occur 0 per person 300,000 Fireworks Display BGL21 4.0 100, 000 per occur 0 per person 300,000 Construction Oversight BGL21 4.0 100, 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). CHH1 (03/06) 150626