SAMPLE. Commercial Liability Coverage Part $ Liquor Liability Coverage Part $ See Endorsement EOD (1/95)

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Authorized Representative NEW

No. CL 1717481

Test 123 Main Street New York, NY 10001

POLICY PERIOD: (MO. DAY YR.) From: To: FORM OF BUSINESS:

BUSINESS DESCRIPTION:

12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.

NAMED INSURED AND ADDRESS:

Renewal of Number

POLICY DECLARATIONS

09/05/2015 09/07/2015 Individual

Special Event

United States Liability Insurance Company

1190 Devon Park Drive, Wayne, Pennsylvania 19087

A Member Company of United States Liability Insurance Group

Coverage Form(s) and Endorsement(s) made a part of this policy at time of issue

See Endorsement EOD (1/95)

Agent: (223) Issued: 09/01/2015 9:01 AM

Broker:

By:

UPD (08-07)

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.

HOME OFFICE - B

1190 Devon Park Drive South Wayne, PA 19087

THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.

WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.

NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING

REQUIREMENTS OF THE NEW YORK STATE

INSURANCE DEPARTMENT. HOWEVER, SUCH FORMS AND RATES MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS.

(Free Trade Zone Statistical Code 2-14141)

Direct Bill Policy

PREMIUM

Commercial Liability Coverage Part $506.00

Liquor Liability Coverage Part $45.00

TOTAL: $551.00

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Description of Endorsements

Endt# Revised

The following forms apply to multiple coverage parts

CG2173 01/08 Exclusion Of Certified Acts Of Terrorism

IL0017 11/98 Common Policy Conditions

IL0268 01/11 New York Changes - Cancellation And Nonrenewal

L-224NY 06/11 Punitive Or Exemplary Damages Exclusion

L-381 11/04 Warranty Endorsement - Equal Or Greater General Liability Limit

L-535 09/02 Exclusion - Products- Completed Operations Hazard

L-607 Exclusion For Climbing, Rebounding And Interactive Games And

Devices 02/11

L-608 02/11 Exclusion For Firearms, Fireworks And Other Pyrotechnic Devices

L-609 02/11 Animal Exclusion

L-616 11/09 Host/Special Event Coverage Form Change Endorsement

L-656 02/06 Extension Of Coverage - Committee Members

LLQ368 08/10 Separation Of Insureds Clarification Endorsement

ME Jacket 09/10 The Main Event Special Event Commercial Liability Policy Jacket

NTE NY 01/15 Notice Of Terrorism Exclusion

SPE 305 03/13 Special Jewelry Coverage Endorsement

IL0023 07/02 Nuclear Energy Liability Exclusion Endorsement

L-387 03/06 Exclusion - Mechanical Rides

L-610NY 01/07 Expanded Definition Of Bodily Injury - New York

LLQ100 07/06 Amendatory Endorsement

LLQ101 08/06 Expanded Definition Of Employee

LLQ102 08/06 Event Vendor/Exhibitor & Contractor- Exclusion Description of Endorsements

Endt# Revised

The following forms apply to the Commercial Liability coverage part

CG0001 12/07 Commercial General Liability Coverage Form

CG0068 Recording And Distribution Of Material Or Information In Violation Of Law Exclusion

05/09

CG0163 07/11 New York Changes - Commercial General Liability Coverage Form CG2011 04/13 Additional Insured-Managers or Lessors of Premises

CG2136 03/05 Exclusion - New Entities

L-423 02/11 Exclusion For Structure Collapse

L-472 07/08 Exclusion - Injury To Performers Or Entertainers

L-536 09/09 Exclusion - Participation In Athletic Activity, Physical Activity Or Sports L-599 Absolute Exclusion for Pollution, Organic Pathogen, Silica, Asbestos and

Lead with a Hostile Fire Exception 10/12

L-686 10/12 Absolute Exclusion for Liquor and Other Related Liability

L-721NY 02/09 New York Changes

SPE 300 05/09 Special Events Property Damage Amendment

FORMS AND ENDORSEMENTS

EXTENSION OF DECLARATIONS

Policy No. CL 1717481

Effective Date: 09/05/2015

12:01 AM STANDARD TIME

All other terms and conditions remain unchanged.

EOD (01/95) Page 1 of 2

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FORMS AND ENDORSEMENTS

EXTENSION OF DECLARATIONS

Policy No. CL 1717481

12:01 AM STANDARD TIME

SPE 306 11/12 Cancellation or Postponement Coverage

SPE 307 11/12 Lost Deposit Coverage

SPE 308 03/13 Event Gift Coverage Endorsement

SPE 309 11/12 Wedding Attire Coverage

SPE 310 03/13 Photography And Video Coverage Endorsement

CG2139 10/93 Contractual Liability Limitation

CG2144 07/98 Limitation Of Coverage To Designated Premises Or Project

CG2147 12/07 Employment-Related Practices Exclusion

CG2621 New York Changes - Transfer Of Duties When A Limit Of Insurance Is

Used Up 10/91

Description of Endorsements

Endt# Revised

The following forms apply to the Liquor Liability coverage part

CG2603 04/09 New York Changes - Liquor Liability Coverage Form

CG2635 New York Changes - Transfer Of Duties When A Limit Of Insurance Is

Used Up 12/93

L-618CNY 08/11 Amendment Of Premium Audit Conditions - New York

L-657 01/11 Absolute Pollution Exclusion - Liability

LQ-352 09/08 Event Vendor - Other Insurance

LQ-354 10/09 Limitation Of Coverage To Insured Premises

CG0033 12/07 Liquor Liability Coverage Form

L-559 11/10 Additional Insured - Manager Or Lessors Of Premises

All other terms and conditions remain unchanged.

EOD (01/95) Page 2 of 2

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Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue:

See Form EOD (01/95) and Form SOE (03/10)

LIMITS OF INSURANCE

Each Occurrence Limit $1,000,000

Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000

Medical Expense Limit (Any One Person) $1,000

Damages To Premises Rented To You (Any One Premises) $100,000

Products/Completed Operations Aggregate Limit See See L-535

General Aggregate Limit $2,000,000

Event Gift Coverage Limit $5,000

Special Jewelry Coverage Limit $8,800

Lost Deposit Coverage Limit $6,000

Wedding Attire Coverage Limit $8,000

Cancellation or Postponement Coverage Limit $45,000

Photography and Video Coverage Limit $8,000

LIABILITY DEDUCTIBLE $0

LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY

Location Address Territory

1 Test Venue 987 Bayshore Drive, New York, NY 10001 001

PREMIUM COMPUTATION

Advance Premium Evt # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other

1 Wedding (applicant is the host of the event) 00410 250 Attendees N/A 250.000 N/A $250 1 Additional Insured - Managers or Lessors of

Premises 49950 1 Per Additional Insured N/A 0.000 N/A $0

1 Event Gift Coverage 00448 Per Event N/A 25.000 N/A $25

1 Special Jewelry Coverage 00449 Per Event N/A 26.000 N/A $26

1 Lost Deposit Coverage 00450 Per Event N/A 25.000 N/A $25

1 Wedding Attire Coverage 00451 Per Event N/A 21.000 N/A $21

1 Cancellation or Postponement Coverage 00446 Per Event N/A 135.000 N/A $135

1 Photography and Video Coverage 00447 Per Event N/A 24.000 N/A $24

MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $1

TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART:

(This Premium may be subject to adjustment.) MP - minimum premium $506 CL 1717481

COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Effective Date: 09/05/2015

12:01 AM STANDARD TIME Policy No.

Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988

Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission.

THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.

CL150 (10/03) Page 1 Of 1

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Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue:

See Form EOD (01/95) and Form SOE (03/10)

LIMITS OF INSURANCE

Liquor Each Common Cause Limit $1,000,000

Liquor Aggregate Limit $2,000,000

LIABILITY DEDUCTIBLE $0

LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY

Location Address Territory

1 Test Venue 987 Bayshore Drive, New York, NY 10001 001

PREMIUM COMPUTATION

Advance Premium Evt # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other

1 Wedding (applicant is the host of the event) 00400 250 Consumers N/A 45.000 N/A $45 1 Additional Insured - Managers or Lessors of

Premises 49950 1 Per Additional Insured N/A 0.000 N/A $0

TOTAL PREMIUM FOR LIQUOR LIABILITY COVERAGE PART:

(This Premium may be subject to adjustment.) MP - minimum premium $45 CL 1717481

LIQUOR LIABILITY COVERAGE PART DECLARATIONS

12:01 AM STANDARD TIME Policy No.

Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission.

THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.

LQ 150 (02/09) Page 1 Of 1

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Subject to the terms and conditions of this policy, coverage is provided for a maximum of twenty-four (24) hours after the scheduled end date of an event shown above.

End Date

Test Venue 987 Bayshore Drive, New York, NY 10001

Start Date Event

Location(s):

Wedding (applicant is the host of the event) 09/05/2015 09/05/2015

EXTENSION OF DECLARATIONS

Policy No. CL 1717481

SCHEDULE OF EVENTS

Regardless of the dates shown on the Declarations, this insurance applies only for the location(s), event(s) and date(s) specified in this Extension of Declarations.

SOE (03/10) All other terms and conditions remain unchanged. Page 1 of 1 THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.

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Additional Premium: $

Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who is An Insured is amended to include

as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional

exclusions: With respect to the insurance afforded to these

additional insureds, the following is added to Section III - Limits Of Insurance:

A.

B.

1. 2.

Any "occurrence" which takes place after you cease to be a tenant in that premises.

Structural alterations, new construction or demolition operations performed by or on behalf of the person (s) or organization(s) shown in the Schedule. 1.

2.

The insurance afforded to such additional insured only applies to the extent permitted by law; and

If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

However:

whichever is less. 1.

2.

Required by the contract or agreement; or

Available under the applicable Limits of Insurance shown in the Declarations;

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amout of insurance:

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. This insurance does not apply to:

Test Venue 987 Bayshore Drive New York, NY 10001

09/05/2015 Effective Date:

Name of Person(s) Or Organization(s) (Additional Insured):

Designation of Premises (Part Leased To You):

Test Venue 987 Bayshore Drive New York, NY 10001

POLICY NUMBER: CL 1717481 COMMERCIAL GENERAL LIABILITY

CG 20 11 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

CG 20 11 04 13 Page 1 Of 1