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Home My WebLink About96-02478 1, Plaintiff iB Doneqal Mutual Insurance Cas" an insurance coapany duly authorized to issue insurance policies in the Commonwealth of Pennsylvania, :Z, Defendant is Richard , Mary Swartz individually and as husband and wife, jointly and severally and as joint tenants by the entireties trading as Fox's Pizza with a place of business at 1832 Steretts Gap Avenue, Carlisle, PA 17013, 3. Plaintiff, at the request of Defendant, or Defendant's authorized agent, issued a Worker's Compensation and Employer's Liability policy naming Defendant as the insured. A tr.ue and correct copy of the policy is attached hereto, incorporated herein and marked Exhibit "A", 4. The total standard premium for the insurance year set out in the policy was $7,609.00, In accordance with the rules, rates and classifications of the Pennsylvania Worker's Compensation Bureau (PWCB) and the premium endorsement, the estimated premium is subject to increase or decrease in accordance with the actual payroll figures established by the insured but not available at time of policy issuance, 5, Plaintiff was permitted to audit the true and correct books and recorda of the Defendant. 6, As a result of Plaintiff'S audit of Defendant's payroll, an adjusted premium of $2,672.00 became due and owing Plaintiff by Defendant for insurance year as set forth on the finAL earned premium adjustment endorsement, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "A", 7, All credits to which Defendant is entitled are set forth on the statement of account, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "A", 8, By virtue of the foregoing, Defendant is indebted to Plaintiff in the amount of $2,672,00 for an additional premium. 9, Al though Plaintiff has made demand upon Defendant for $2,672,00, Defendant has failed and refuses to pay the same or any part thereof, WHEREFORE, Plaintiff demands judgment against the Defendant for $2,672,00 with interest from January 26, 1995 at 6' and costs thereon on Count I, COUNT II 10, Plaintiff at the request of Defendant and/or Defendant's authorized insurance agent, issued an insurance policy of the kind and type as more fully set forth and attached hereto and marked as Exhibit "B", naming the Defendant as the insured. A true and correct copy of the insurance poi icy declarations described above are attached hereto, incorporated herein and marked Exhibit "B", -1- ) ~)2 fie [.j t!(J (' It s l2 .') . /- ',' /, (I, , ,) I i',\ .) 1'/ l ). -L- _ / 9(\ (.'\ ~Y7t"1/1' M,\lLING ;\nORE~5 IIIlCI,:t:;--.:Z.1.l t' j,'.l I Rei /~ {~l /' Irst 4 j? {J/3 ------ 1"'IlVtllll"l. 1.\ "l\nll'l(rl."IIII' EMPI...OVE R 1,0. NUMBe n CQnl'onArlON '1THEn RArtNO BUREAU 1.0. NO. Y""~l,j'I""1I . ~rnFr:r CITV COUNr'~ <';r^rE "Ir'!:()r)~- /1c\/, -~)'//'7J~-,u_(_~/{'lf ~ ({J~~"b Cd' --;-1 - / '7{))3 / -------------.--- 3 I")l ,e , '"'''''' n "'ono>1,/?':'5"""OlJ <', PAeviiJUSPOL 'CY~~R~R rlc;A TING NON PAnrICIP,\TING COVF.R.\Gl: ^ IS r., fE',i----- rriyF"'fl^~~~llll,;;;:;;~1"'()J(T):J' .- -." _______ , I ^"E" 1'/': 'r' nil!. J~___._____._~._~cr IJILl SPECIAL COMPANY ANa :;rA TF. INFOFlM.\fION PReVIOUS INSURER Pr,,"PO~f!,j ~ ?it'! (I'-.I"III)0IV'(1 Dividend PI,Ii/s,r'IV Group "E TAQ PLAN p., vM!:,:rj r I'I.ArJ UOrr PEAI(~'J ."NNIjAl ~'T EXPI~lATION SEM!.AN,iUA L SEMI.ANNUAl- CA n::r;onll::s. OUTIES. Cl-A$SI FICA nONS R. sh V;/';/L is , - :f'!:' C00 , .." ~ ' . ;I'ECI F Y ~.OC ITIQNAL. COVEnAOES/E NO(JnseMe N TS ~ BROAD FO~M Al-l- STATES US.I... & H. VOI.VNTAnv COMI'IlNSATION OTHllF\ TOTAL S eXPEAIENC/i MODIPICATION "'~Olflleo PReMIUM $ . . ----- PREMIUM Ol$COUNT S . .-~-,., ',., TOTAL. eSTIMAT!C)",_,u-,,,, sY PO","'>! IIll/Io ANNUAl. PREMIUM '1""1 "1 ,", ~'.... ."," MINIMUM . '1."11 I It'" I "11..'11.1,""" :;L_t)_~.~~_~~ ,fJ>:'tL , "'II ItH: "'" -::'rL\;I,~] ,,,,~,m,,, "!!~ 1 --/~~fAlclSt~Ar. - -CSJ -_.--'-~ , --l--.I-------- -~.I i DONEGAL' (]~ M"'"E TTA, PENNSYLVANIA t 7547-0302 HOME OfFICE COpy STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - STANDARD RENEWAL POLl CY CARRIER ~ 15636 WC 00l3644-01 Ol/Ol/94 Ol/Ol/95 WC 0013644-00DONEGAL MUTUAL INSURANCE 0004321 l. RICHARD & MARY SWARTZ T/A FOX'S PIZZA 1900 SPRING RD CARLISLE PA l7013 FEIN ~ 000000000 RISK ID ~ NO ADDITIONAL LOCATIONS ENTITY OF INSURED - PARTNERSHIP 2. POLICY PERIOD - Ol/Ol/94 TO Ol/01/95 12:01 AM STANDARD TIME AT THE MAILING ADDRESS OF THE INSURED AS STATED HEREIN. J RODNEY FICKEL INS AGY INC 15l W HIGH ST P 0 80X l CARLISLE PA 17013 (717) 249-2812 3. COVERAGES A, WORKERS COMPENSATION INSURANCE:PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE:PA. B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $lOO,OOO EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C, OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT NV, ND, OH, WA, WV & WY D, THIS POLICY INCLUDES THE FOLLOWING ENDORSEMENTS: WCOOOOOO WC000404 ZZ 4 0591 WC370601 WC370602 WC370603 4. THE PREMIUM FOR TillS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. PREMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. ST LOC CODE CLASSIFICATION OF OPERATIONS EST CLASSIFICATION DESCRIPTION TOT-TERM REMUN EST TERM PREMIUM RATE PER $100 REMUN PA OOOl 975 RESTAURANT 35,000 6,07 p~rT'~'I':<.-':, l)0!1nll , ' ., r f 1! II 1 ~ 2,125 MINIMUM PREMIUM (PAl $745 EXPENSE CONSTANT: (PAl ESTIMATED ANNUAL PREMIUM: DEPOSIT PREMIUM: $140 $2,265 $2,265 ISSUE DATE lO/28/93 ISSUING OF~'ICE: COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSA;1~~ PreSIdent DONEGAL' e~ MARIETTA, PENNSYLVANIA 17~47,0302 !t~~l~ v~r~L~ LV~L STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - STANDARD AMENDED POLICY - Ol/Ol/94 SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD CARRIER ~ 15636 WC 00l3644-01 01/01/94 01/01/95 WC 00l3644-00DONEGAL MUTUAL INSURANCE 0004321 l. RICHARD & M~RY SWARTZ T/A FOX'S PIZZA 1900 SPRING RD CARLISLE PA 17013 FEIN ~ 000000000 RISK ID ~ J RODNEY FICKEL INS AGY INC 151 W HIGH ST POBOX l CARLISLE PA 17013 (717) 249-2812 NO ADDITIONAL LOCATIONS ENTITY OF INSURED - PARTNERSHIP 2. POLICY PERIOD - 01/01/94 TO 01/01/95 12:01 AM STANDARD TIME AT THE MAILING ADDRESS OF THE INSURED AS STATED HEREIN. 3. COVERAGES A. WORKERS COMPENSA'rrON INSURANCE: PART ONE OF THE POLICY APPLI ES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE:PA. B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT NV, ND, OH, WA, WV & WY D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS FORMING A PART OF THIS POLICY. 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. PREMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. CLASSIFICATION OF OPERATIONS EST TOT--TERM REMUN RATE PER $100 REMUN ST LaC CODE CLASSIFICATION DESCRIPTION PA 0001 975 RESTAURANTS 35,000 5.53 MINIMUM PREMIUM $745 (PA) EXPENSE CONSTANT: (PA) ESTIMATED ANNUAL PREMIUM: DEPOSIT PREMIUM: ~ 'tHE FOREGOING AMENDMENT RESULTS IN A RETURN PREMIUM OF: J' ISSUE DATE 01/25/94 . ISSUING OFFICE: . CL-J(1IB9) (,()PVRT~H'T' ,QR7 NArrrnNAT, rnrtNrrT. ON C()MPP.N~~~~ EST TERM PREMIUM 1,936 $140 $2,076 $2,076 $189 Prllllldont DONEGAL' e~fUUUU MARIETTA, PENNSYLVANIA' 7547.0302 hUM"; ul.nCI:; lUt"/ STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - STANDARD AMENDED POLICY - Ol/Ol/94 CHANGE IN COVERAGE SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD CARRIER ~ 15636 WC 00l3644-01 01/01/94 Ol/Ol/95 WC 00l3644-00DONEGAL MUTUAL INSURANCE 0004321 l. RICHARD & MARY SWARTZ T/A FOX'S PIZZA 1900 SPRING RD CARLISLE PA 17013 FEIN ~ 000000000 RISK 10 ~ NO ADDITIONAL LOCATIONS I ENTITY OF INSURED - PARTNERSHIP 2. POLICY PERIOD - 01/01/94 TO 01/01/95 12:01 AM STANDARD TIME AT THE MAILING ADDRESS OF THE INSURED AS STATED HEREIN. J RODNEY FICKEL INS AGY INC 151 W HIGH ST P 0 80X l CARLISLE PA 17013 (717) 249-2812 3. COVERAGES A. WORKERS COMPENSATION INSURANCE: PART ONE: OF THE: POLl CY APPLI E:S 'fO THE: WORKERS COMPENSATION LAW OF THE STATES LISTED HERE:PA. B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIE:S TO THE STATE:S, IF ANY, LISTED HERE: ALL STATES E:XCEPT NV, NO, OH, WA, WV & WY D. SEE ATTACHED SCHEDULE: FOR LIST OF ENDORSE:MENTS FORMING A PART OF THIS POLICY. 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. PREMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. CLASSIFIC^TION OF OPERATIONS EST TOT-TERM REMUN RATE PER $lOO REMUN EST TERM PREMIUM I ST LOC CODE CLASSIFICATION DESCRIPTION I PA OOOl 975 RESTAURANTS 64,l78 5.53 3,549 MINIMUM PREMIUM $745 (PA) EXPENSE CONSTANT: (PAl ESTIMATED ANNUAL PREMIUM: DEPOSIT PREMIUM: IN AN ADDITIONAL PREMIUM OF: $140 $3,689 $3,689 $1,613 THE FOREGOING AMENDMENT RESULTS i I SSUE DATE 05/18/94 ISSUING OFFICE: Cl.J(7/89) ('()PVRT~I-tT lqA7 NArrT()NAr. ('OtlNrrr. ()N r()MP~Nc:.~~~ DONEGAL ' e~ MARIETTA, PENNSYLVANIA 11~"0302 II '.J I'I~:' \.) I.. I.' ~ l. J,'~ l.... ,.) t' ! STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY IN~ORMATION PAGE - STANDARD AMENDED POLICY - Ol/01/94 SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD CARRIER U 15636 we 00l3644-01 Ol/01/94 01/01/95 WC 00l3644-00DONEGAL MUTUAL INSURANCE 0004321 l. RICHARD & MARY SWARTZ T/A FOX'S PIZZA 1900 SPRING RD CARLISLE PA 17013 FEIN # 000000000 RISK ID # J RODNEY FICKEL INS AGY INC 151 W HIGH ST POBOX 1 CARLISLE PA 17013 (717) 249-2812 SEE ATTACHED SCHEDULE FOR ADDITIONAL INSURED LOCATIONS ENTITY OF INSURED - PARTNERSHIP 2. POLICY PERIOD - Ol/01/94 TO 01/01/95 12:01 AM STANDARD TIME AT THE MAILING ADDRESS OF THE INSURED AS STATED HEREIN. 3. COVERAGES A. WORKERS COMPENSATION INSURANCE:PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE:PA. B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $lCO,OOO EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT NV, ND, OH, WA, WV & WY D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS FORMING A PART OF THIS POLICY. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO V~RIFICATION AND CHANGE BY AUDIT. PREMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. ST LOC CODE CLASSIFICATION OF OPERATIONS EST CLASSIFICATION DESCRIPTION TOT-TERM REMUN RATE PER $lOO REMUN EST TERM PREMI UM SEE EXTENSION OF INFORMATION PAGE 4,655 MINIMUM PREMIUM $745 ( PA) EXPENSE CONSTANT: (PA) ESTIMATED ANNUAL PREMIUM: DEPOSIT PREMIUM: IN AN ADDITIONAL PREMIUM OF: $140 $4,795 $4,795 $l,106 THE FOREGOING AMENDMENT RESULTS ISSUE DATE 06/10/94 ISSUING OFFICE: CL'3(7/89) r()PVAT~J.{T , qA7 NATTONAr. ("()[JNC'TT. ON (,()MPF.N~~~~ President DONEGAL e~ MARIETTA, PENNSYLVANIA 17~.7-0-J02 HuM I:. vr r' I CI:. CU",'{ STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INfORMATION PAGE - STANDARD AMENDED POLICY - Ol/01/94 I : 5UPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUM8ER AND POLICY PERIOD CARRIER * 15636 ~c 0013644-01 Ol/Ol/94 01/01/95 WC 00l3644-00DONEGAL MUTUAL INSURANCE 0004321 1. RICHARD & MARY SWARTZ T/A FOX'S PIZZA 1900 SPRING RD CARLISLE PA 17013 fEIN * 000000000 RISK ID * J RODNEY fICKEL INS AGY INC 151 W HIGH ST POBOX l CARLISLE PA 17013 (717) 249-2812 POLICY E X T ENS I o N o l" I N f o R MAT I 0 N P AGE PAGE 2 CLASSI fICATION Of OPERATIONS EST RATE EST ST LOC CODE CLASSIfICATION DESCRIPTION TOT-TERM PER $lOO TERM REMUN REMUN PREMIUM PA 0001 975 RESTAURANTS 64,l78 5.53 3,549 TOTAL FOR LOCATION 0001 3,549 0002 975 RESTAURANT 20,000 5.53 1,106 TOTAL FOR LOCATION 0002 1,106 TOTAL FOR PENNSYLVANIA 4,655 .,. ,. , , . ~ . , .1' ~ "'" 1987 NATIONAL COUNCIL ON COMPENSA;1~.~ Presidenl ~I Donegal Mutual Insurance Company I I Atlantic States Insurance Company AUDIT SUMMARY Policy Number ~~__0.Ql~6,+{~()l Insured TR ~~~[~_~~!y'~:"':r tz T / A ox s . zzn . LEGAL-EJ~~.TJ!'i ~...l~soloproprloto~~6:sarlneA~ibu~ cO:;'d:tb0tl~SBY CODE- TITLE lAME PAYROLL INCLUDED #.- # li--- ._- -"-'7, 1 . . jt,r,' ..sit.." J::. ..r.>w! n filCh/Jt, Wl.~ ~7 ,'~_7{i,h !J~Loe2 p DESCRIPTION OF OPERATIONS Period _l!:L1..~,!!:-1 /01/95 Address _t2?O__~~~~I~~_Rd.~,~~rli51e, FA 17013 DESCRIPTION OF DUTIES ..... -._1 - -.'. -- ... -.. ------,-- ._...____...___....u. ._.__~____u_____.__ ".,. ..-.---.-.---------,--.---- ~OT~~b;~P ~z-' .M..___.__,_ . PAYROLL S ,ca 01 Oalo . _____,_ ...._VJ;fl{l~AJJQ'L___ Ii ~~~'~I~~g~k c,;<}'}~%SAnOfJ !QJFL _219...2-"k...._ : 1 gh.W~~k - ., .:;~..L_1QT8,q'l _LZl~33...._ II G:~'I JOu~n"<:1 . "_-__ S g+~,l _2g3S~__._ V"lflcoUon ~r:2,\?lL !{~___, 2. _'1.L,L.._ U 15 A.turn. _ _ .._:~:_:=cc:,,=-~~ . 01:: ~ 2 . ~IC Aal~rn. L 0 C 2 F~~jl ;~olam.n _ W.. There Vel No o 0 OlJerUme [] [] Max, Wog. [] [J Min. Wog. D 11 Lodging ,11 D Bonus D D Comms, [J 11 C.sual Labo, -.---- [1 U Subconlracl'Jrs U [J ClasslflcaUon --, ---...-,------.---.- ---- .-..-------. -.-------- fO'fAL chan~.s TOTALS (for verification purposes only) /31. /pO I ~~yD~1",,6~.E /301/ RY i5 i1 ~:~~:a~'~;;cp .PlI~!SlS;---,)J'~rPQllcYHndt's: ~Q ndL i;MLD~~d~d. seed~lnlL!l!lnch~d__m AUDIT LOCATION ~_~_~rr~ctors ____ ... ....... _ [un ........ L___ ...... ._~O~l____~ ... "_'_ NAME _ ~jlll-..ff;;5S_~_. Pr ~~ .~-~= -~~==--..~=-=.=-'''' .~=-_--=--:-=~_~~~j~~=:_~~~=-:= STREET _,.l3~ S:_ljAn~ve r- -- -=:==-=--::=====::::-:'.:=-:::=::::-:::-":::-=-==~:~'--' CITy.j:'~f. /1 i1~ -- -~-- --~_._---- -----. ---'----~-_._~--------_.._,..._----~-- .12 --- __......___._m_..__.__..___._.... ....___._,_.....____.___~ _.._ _..._ STATE __I::....~_, ~trl\r4~i- =:::::=~::::::=- --:- [=:::--::C.::.:--':::= C9$t-~:~:=::::==: PHONE ... d'1.3 -11!/3 ______,. __ m _ .._ . AU_OJTSIJ MAR)' S(:r.E'1}J.S.li.CtTIONC ~O~E.., .~IABILITY.. ..... S L t:. I. '11.. .. .~: -. hl.J:)7)~2~ (~?f --.. -------_.-.--- --_.-"- .----_._-~~- "-.---- -----.----- ------ ----.- .---- -,----..~--,-+~- ----_._._.___ _0_____- _ - .....---.- .-.----..,- -_..._~_.__.._--- ________._n _~___.___ Permission for Insurance company 10 release audit 10 agent or broker II Yes U No Inilial h. ::;::~ ~-'9-~~~ AUO.2 (2/9Q) ... _ .___ '_m~__'.__ ..._____>--"__ ___.....__._.._.__~_.~._____. Date _..l~~-9~___ III ;)one9al Mlllual Insurance Company I'J Allanllc Stales Insurance Company Polley No,he 0013641, 2.lL cpp ~~26:U_c)._~.1..___ Period dUO 1 / 94_:])0 1 / ~~__.______ Inaured ltti~clh~rd,& ~1ry Swar~ AddreSl1~~~~~~in~ Rd.,ea.~lls1e,I~~_~7013 __ .L UK ,~ :t:.;t;c.:t - 12.1'1 A;; i1)It~S : I? 1:::;;;;. ve I(L?'JI"AJ ;a.n-J ~S'<tL -1 / IU 1tI'-. -~-,-~ ----.----. f----.....---....-. _._-~------._-_._- -..----..---,. --~_._- -.---.------ .---- -2. -~_::~- ___<:::2.__.__ _.._~_._.-.. f----------- .-- '--p;;;,' --- ---- ~ r~y-'t=.. ~1J..'7,q-- I------.{j-- I-- __.;.) .__-= --ZJ'- -~~---- .::::.&-~- -.--- .3 -':;53 ------ ~ 7.. Ii Tt:;'LL' ;~-.3:.__ ---_._-,------ =-,.. _?!:~~~~-:..-= 7(.;t?a3- 1----.--- f-4~-- --- t---'>---.- - -.+- - f---------.-. -2~~' ~ ~'i-L"'13l= 1-J.2.CL~.5::.- ~(l3--'1= 1----d:3i2J!L-_ -)4TFl~ .-----.- -,<J !4, . .Jl. -"----.-- - --n-Pi r------ "j -.--.-..-.-- 1------..- . .--- 1Q ~i.k-L~ ;=~lJ.3.5_=:= "-;;'13'1"-- -7.~L ~.L-fl}j'v 11 7' .-- -- ... --"- ..:.J_ _ -.-. 5 J..2 1(" ~~-(ri- I-~~T:- L'-('~i)l 0;'..2.___ 1_ ~ct::=_,_, . U I,I/lh _t.1l.~_y..ir.a: 1.4 WLE-,- ~2(i~..1 .-------.-- e---. ._ - 12 . ' ' - -.-.----..-- --.-.,..--.. .. ---== '- - ---.---- -------------- f-- ~ ~(j- ~1 ~\S'1 _ca:c:;:qL' ~i._l=-_--= i4.iue:~~ f--... u :ti~_: P-'- ~ vr'fV/U111 7 ~~..o~ 1-----.. off WC- , 11! t!:W-::' 1-.-.-- -f--- ~{ f-J:.LV C/L1 .~ +------ f---- , " " "'~ r-19 f.?::;I. ~ ?~ IV " ---- ~ ~4 ? CSl- 'T qU ~ V ~ ...." I .LI ~T /.ILl :::!/J ,.q / /J \ / ~, 2.' , 2.~ '7~J....1/ )(t;" "<.!II -:1./ !LQ J ~1 , ,1 ~4 - - ;),.2 .. ~ -- ., aJl ~ - 41 - - 4' 4 - ~ ~ 1-, 1Jl i.~ .. 5.Q 1------ f-. -- 5j 1---. , 1----- 5_L ...- 5~ -- .-. Permission 'or Insurance company 10 release audlllo agent or broker [J YES 0 NO Initials __ Signature ~1n:.......g,/m'-'/ __._,__________ Dale ----.I..-,;I/; ~9.!J- _ Page No, _!... of ~ Position _ DONEGAL e~ MARlEnA, PENNSYLVANIA 17547-0302 WC 0013644-01 01/01/94 1. RICHARD' MARY SWARTZ FOX'S PIZZA 1900 SPRING RD CARLISLE PA 17013 FEIN * 000000000 RISK POLICY PAGE 1 Ol/Ol/95 T/A 10 * HUME UFF r CE CU"V . WORKERS COMPENSATION .FINAL AUDIT STATEMENT AUDIT PERIOD Ol/01/94 TO 01/01/95 CARRIER * 15636 WC 0013644-00DONEGAL MUTUAL INSURANCE 0004321 J RODNEY FICKEL INS AGY INC 151 W HIGH ST POBOX 1 CARLISLE PA 17013 (717) 249-2812 CLASSIFICATION OF OPERATIONS RATE; ST LOC CODE CLASSIFICATION DESCRIPTION TOT-TERM PER $100 TERM REMUN REMUN PREMIUM PA 0001 975 RESTAURANTS 85,321 5,53 4,718 0002 975 RESTAURANT 52,280 5,53 2,891 TOTAL FOR PENNSYLVANIA 1987 NATIONAL COUNCIL ON COMPENSATjON I~4R~~E nLl.......u... N ~ Presldenl 7,609 . , . Kl Donegel Mutuel Inlurence Company [J Atlentlc States Insurence Compsny . . Policy Number~ 0106229_ 01 I d Richard & Mary Swartz nsure AUDIT SUMMARY Period 1/01/94-1/01/95 Address 1900 Spring Rd. ,Carlisle,PA 17013 'r/A " i Fox's Pizza \ J \ ./ LEGAL ENTITY I 0 Sole Proorletor ~ Partnership iI' Corporation . GFlClSS AMOlJ~f %OF1iUTlESBY CODE-'-' TITI,E ~y PAYROLL INCLUDED 1/ 1/ 1/ DESCRIPTION OF DUTIES I MITT - - - ~ ._-- -, --- - Hlb *"/ r --.--- "---- -- - VP -r 1/......""1 DESCRIPTION OF OPERATIONS ______ ~--- .. - -----~--~_. ,- -- NOTES TO COMPANY lJ. ~_.U "'.. .fl.+- In_ 1-:=..~k..!i.S. 11 AUDI ~ ..suMMAR PAYROLL Sourc. ot O.te ~ o Payroll Book o Cash Book FrrATI= C.I~IC'.ATI.QI'!. 'CO[J~ .TrIlBtTY '~"P~~AI!Qtl. OTR, o Checkbook f/~ ~,' LAt". / ( I 1026, II ) OTR, lJ Gen'l Ledger [J Gen'l Journel " OTA. I I/rJ ~A-r JA.....", ( 'WL r, JiJq I-/~t- '" Q111... \ VorlllclUon o SlS ReMns '- -_....:- ---- \ o UtC Returns \ -- LJ Income Tax -- --- o Financial Stalemun I 0 I WII Thor. \ 'III No o 0 Overtime o 0 Max, Wege [) 0 Mln, Wege o 0 Lodging o 0 BonlJs -. o 0 Comms, o 0 Casual Labor - o 0 Subcontractors ..- t-' o 0 Classlllcallon IUIA~ changes TOTALS (for verification ourposes only) 5/1,113 ~~';>~~~LLe \ [I U Standard excp o [] Alrcra" Expo ~--D...Pill..Q]jaUMtJ,--,-~....D.MLD.~~J!~Mtl!.!l attached AUDIT LOCATION Ind. Cost -;fn h fl JIb ~5 k r- (!!1l I =r::::=c= ____._ NAME .fr.QdJ _.___--"!!l~lllots ~--- !J3~ S. &bvt!:r f------ '-' --~-_._- STREET '"- -- _Oilr/Js.-/~ --- ~._.._-_._--_._.._,-- CITY ---- --- -----_._------~~----- (JOJ - -- -_.- ----- -------------,-----.--... -.----- STATE ~5~- .____" .______ ___,__uo__________. .__h__'________ ...d!J3 ~'17'/'3 - ---"'I~':::=I- _._.._._.G9.~L_.__ .--- PHONE Permission for Insurance company to release audll to agent or broker rJ Yes U No Initial ::;I::~ n 0:-[ aJ+--.... .._u_._______u._____.____... 2 -:J 9~:"- ----rr-r'11 rzw.._...n__.._",__ Dale -.. AUO,2 (2J90) , . Xl Donegal Mutual Insurance Company [J Atlantic States Insurance Company AUDIT SUMMARY Policy Number CPP 01062)9 OL____ Period Jj01/94-1/01/95 Insured Richard_~ ~la~L~:-'~::~~ 'I/A .__, Address 19~O Spring Rd. ,Carlisle,PA 17013 LEGAL l~r'ff-.f--:J~]~e!'r~@ei~~~6:;!ln~1~~~~6;W~iE;'~~CbbE TA:LE _ NAME ,___ _ P~YR2LL. INCLUDED f-;j'- # # DESCRIPTION OF DUTIES PA& '~,~ r( ~~~:_~~:~-:~:- ,'=~~===___ ~_-~~ _=._~-- r-- . . vP ,. V... ...."'uJ DESCRIPTION OF OPERATIONS .__, ___.____________... -------.-.-- .__.~~-~ . -... .._~-_._----------_._------ ____..~_u_______._ .. . --_.._--------_.._'---_.~_.._---_. NOTESj~~~_7~~i~~/~~~tJ: ~~::.~~_ ~d.A J J---c.=- _____.____...A!lOlP SUMMARY____~-..--..--.. PAYROLL Sourc. d. Dlta r- -Y~ru;..AnON ri Pavroll Book U Ca.h Book I SJ:j /~J.$J:2;.fQJ .: CQ~~ -:Jt..~~~~~ ...cQ.MF'.EN$~l1QN IJ Chackbook r------O!R.... 1I Oen'lledger _.QI8~ U Oen'l Journol f-~ -a.A~--U-----'--.._.-_.--..--+-------- t---QI8L- - V,rUle,lIon f-Ic....~-_f--....__ -.-----f----- ~..mR.. [] SlS Returns [] UtC A'lu,". ---- --..---- ------- _. [] Income Tax - -- o Financial Stalemen -- 0 - .. --- Woo Th... n. ..... No - 0 D Over1lme f-. ------.- - .-.--- U [] Ma., Wag. ----.- - U [j Min. Wage CJ o Lodging ,-.----- __, -----.. 0 11 Bonu. ..---- -,--_. [] [] Comm.. \ U [] Casual Labor '__'n f----- [] [] Subcontractors . V u u CrassificaUon .---. TOTAL chan~" TOTALS (for uerllicalion purposes only) AUO~i;'LB~ E [] o Sian Ird Excp PAYA L 0 o Airctart Exp. niiMi'SlS: 0 Per E'2JiaUI)QtL:D9,MLll__MLn~_QQesL:..m.d.~~~I!~L_. AUDIT LOCATION ~Iractors-_---:r=-L---~.-- Cost ___. NAME --::kbn-. 110. _L ~~ 'roducls/C.1L-.._______._..___~..,.-.--.-B!!.cmp~-.-. STREET __~E~ ~, ~nlller- --.---------- -------- -_.-.-- -----...--------.-----.- 1--,-,-- --.----.-.-..-- f---- ..- --.--.------.------ _._C14-tlt ~L~_ 1---- -.-------------- ,,-.--- _.~---- -, -------.-- .----- ~-_.._-_._--, _._--~ CITY 1---'- ---------.- .,-......----.-- _..... ...... -- -.-.._-- --_.-._----.---~-.._--.-_..- .-~ _,i?~ 1----- ---_._-----~-~. ------._-- ___n _.,__ - - -..--------..-.--- ... -..--..---...---- STATE ~J,jiAr-~T.~~ -~:.-~=.--:=._:~l---:..:~L_--=-=..:-=-cos(=: -~"...... PHONE ~'13_.72f4- Permission for insurance company 10 release audit 10 agent or broker [) Yes ['] No Initial.__ Insured Audilor ~~~~~~T~t1rh; Dale -___Ht -9 S AUO,2 (2190) , ENDORSEMENT (Attach to poliCy) LU.127 Ed,3/91 AUDIT POLICY PREMIUM ADJUSTMENT The IIs~lmated premium on the policy is hereby adjusted in accord with the audit for the period Indicated, POLICY PERIOD FROM 01/01/94 TO 01/01/95 INCREASE OR ADDITIONAL PREMIUM RmRN PREMIUM DECREASE IN CLASSIFICATION EXPOSURE Prem, Ops, Products Prem.Ops. Products LOC 1 RESTAURANTS 16B14 ACTUAL 36B,311 DEPOSIT lOO,OOO 26B,311 +268,311 $438. MP LOC 2 RESTAURANTS 16Bl4 ACTUAL 149,402 DEPOSIT 50,000 99,402 +99,402 $l93. MP rl ThiS rate is subject to modification under the Commercial Oerleral Liability transition program. TOTALS $631. MP BALANCE DUE: o INSURED 0 COMPANY $ 631.00 Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement. Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. This premium adjustment is for the policy period indicated and forms a part of Policy Number CP P 0106229 Issued to: RICHARD & MARY SWARTZ T/A FOX'S PIZZA Adj, computed at Marietta, PA 4321 J RODNEY FICKEL INS AGY INC (AUTHORIZED REPRESENTATIVE) Oa~ 03/20/95 BRB DONEGAL MUTUAL INSURANCE COMPANY Marietta, PA Agent DONEGAL '(J~ IfARIEITA, PENNSYLVANIA 17547.0302 HuME un'ICE COPY DONEGAL MUTUAL INSURANCE CO. RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL PACKAGE POLICY DECLARATION POLICY NUMB~R CPP 0106229 Ol RENEWAL O~ CPP 0106229 00 POLICY AMENDED, CHANGING COVERAGE E~~ECTIVE: JUNE 01, 1994 THIS SUPERCEDES ANY PREVIOUS DECLARAT10N BEARING THE SAME POLICY NUMBER ~OR THIS POLICY PERIOD. NAMED INSURED AND MAILING ADDRESS AGENCY NAME AND ADDRESS RICHARD & MARY SWARTZ T/A ~OX'S PIZZA 1900 SPRING RD CARLISLE PA l7013 BRANCH: MARIETTA, PA J RODNEY FICKEL INS AGY INC 151 W HIGH ST POBOX 1 CARLISLE PA 17013 AGENCY NUMBER: 0004321 POLICY PERIOD: ~ROM: JAN. Ol, 1994 TO: JAN. 01, 1995 AT 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE, BUSINESS DESCRIPTION: PIZZA RESTAURANT IN RETURN ~OR THE PAYMENT O~ 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 O~ THE ~OLLOWING COVERAGE PARTS ~OR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM COMMERCIAL PROPERTY COVERAGE COMMERCIAL CRiME COVERAGE COMPREHENSIVE GENERAL LIABILITY COVERAGE TOTAL PREMIUM: ADDITIONAL AMOUNT: $3,703,00 $296,00 $598,00 $4,597,00 $652,00 FORMS APPLICABLE TO ALL COVERAGE PARTS: IL 00 17 ll/85 ZZ 4 5/80 IL 02 46 6/89 COMMONNA l/86 IL 09 10 1/81 COMONDEC 1/86 ISSUED 06/16/940' ," :z..... " A~~ PreSident DONEGAL e~ MARIETTA, PENNSYlVANIA 1 7~'70,J02 HUME UFFICE COPY ," '.. DONEGAL MUTUAL INSURANCE CO. RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL PROPERTY COVERAGE PART DECLARATION POLICY NUMBER C~P Ol06229 01 RENEWAL OF CPP Ol06229 00 POLICY AMENDED, CHANGING COVERAGE EFFECTIVE: JUNE 01, 1994 TillS ENOORSEMfo;NT CHANGfo;S THE POLICY. PLEASE READ IT CAREFULLY. NAMED INSURED: RICHARD & MARY SWARTZ IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SU8JECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. TOTAL PREMIUM: $3,703,00 $476.00 THl': PRO-RATED ADDITIONAL PREMIUM IS: DESCRIPTION OF PREMISES: PREM BLD OCCUPANCY 1 1 PIZZA RESTAURANT CONSTRUCTION: FRAME PREM l'ILD OCCUPANCY 1 2 SIGN CONSTRUCTION: NON-COMBUSTIBLE PREM BLD OCCUPANCY 2 1 PI ZZA SHOP CONSTRUCTION: FRAME PREM BLD OCCUPANCY 2 2 SIGN CONSTRUCTION: NON-COMBUSTIBLE PROTECTION CLASS: 05 PROTECTION CLASS: 05 PROTECTION CLASS: 05 , PROTECTION CLASS: 05 ' . ,;. CFCOVERG 1/86 PAGE 1 CONTINUED ISSUED 06/li/94 om' J " .. .' oLl~.1Y ~ PreSIdent DONEGAL e~ MARIETTA, PENNSYLVANIA 1 ;~4;OJ02 HVMI:: VH' I CE COPY . '. DONEGAL MUTUAL INSURANCE CO, RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL PROPERTY COVERAGE PART DECLARATION POLICY NUMBER CPP Ol06229 Ol RENBWAL or CPP 0106229 00 POLICY AMENDED, CHANGING COVERAGE EFrECTIVE: JUNE 01, 1994 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NAMED INSURED: RICHARD & MARY SWARTZ COVERAGES PROVIDED: INSURANCE AT THE DESCRIBED PREMISES APPLIES ONLY FOR THE COVERAGES SHOWN BELOW: SEE FORM NO. COMMONNA FOR POLICY SCHEDULE OF NAMES AND ADDRESSES. PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS 1 2 SIGNS BASIC FORM l,l90 $l2 SPECIAL FORM 0,037 $l LIMIT OF INSURANCE: $l,OOO DEDUCTIBLE: $250 COINSURANCE: 60 % PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS 2 1 BUILDING BASIC FORM O,761 $837 SPECIAL FORM 0,037 $41 LIMIT OF INSURANCE: $110,000 REPLACEMENT COST DEDUCTIBLE: $250 COINSURANCE: 80 % PRr::~1 BLD COVERAGE COVERED CAUSE RATES PREMIUMS 2 1 6USINESS PERSONAL PROPERTY BASIC rORM 0,838 $420 SPECIAL FORM 0.052 $75 LIMIT OF INSURANCE: $50,000 REPLACEMENT COST DEDUCTI8LE: $250 COINSURANCE: 80 % PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS 2 1 BUSINESS INCOME INCLUDING EXTRA BASIC FORM 1,065 $266 EXPENSE SPECIAL FORM O,091 $23 LIMIT OF INSURANCE: $25,000 DEDUC'l'I BLE: NONE COINSURANCE: NONE MONTHLY LIMIT OF INDEMNITY: l/3 CFCOVERG 1/86 PAGE 3 CONTINUED ISSUED 06/1j/94 ~'I , rJJ~L IV ~ Pro,'".nt DONEGAL e~ MARIETTA, PENNSYLVANIA 17~47'OJ02 WUM~ UfflC~ CUPY DONEGAL MUTUAL INSURANCE CO, RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL PROPERTY COVERAGE PART DECLARATION POLICY NUMBER CPP 0106229 Ol RENEWAL OF CPP 0106229 00 RENEWAL NAMED INSURED: RICHARD & MA~Y SWARTZ , IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS I POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. TOTAL PREMIUM: $2,015.00 DESCRIPTION OF PREMISES: PREM BLD OCCUPANCY l 1 PIZZA RESTAURANT CONSTRUCTION: FRAME PROTECTION CLASS: 05 COVERAGES PROVIDED: INSURANCE AT THE DESCRIBED PREMISES APPLIES ONLY FOR THE COVERAGES SHOWN BELOW: SEE FORM NO. COMMONNA FOR POLICY SCHEDULE OF NAMES AND ADDRESSES. PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS 1 l BUILDING BASIC FORM 0,709 $1,184 SPECIAL FORM 0,024 $40 LIMIT OF INSURANCE: $167,000 REPLACEMENT COST DEDUCTI8LE: $250 COINSURANCE: 80 % PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS l 1 BUSINESS PERSONAL PROPERTY BASIC FORM 0,560 $420 SPECIAL FORM 0,033 $56 LIMIT OF INSURANCE: $75,000 REPLACEMENT COST DEDUCTIBLE: $250 COINSURANCE: 80 % FORM NO, CFCOVERG 1/86 CL,J 17189) PAGE 1 CONTINUED ISSUE~ 10/11193'""", J iJ . , oa~ft ~ Pr'Sidsnt DONEGAL (]~ MARIETTA, PENNSYLVANIA 17M7.0JOJ HOME Ol"l"ICE COPY . " " DON~GAL MUTUAL INSURASCE CO. RT 441, BOK 302 . MARIETTA, PA 17547 COMMERCIAL PROPERTY COVERAGE PART DECLARATION ! POLICY NUMBER CPP Ol06229 Ol I RENEWAL OF CPP 0106229 00 RENEWAL NAMED INSURED: RICHARD & MARY SWARTZ COVERAGES PROVIDED: INSURANCE AT THE DESCRIBED PREMISES APPLIES ONLY FOR THE COVERAGES SHOWN BELOWt SEE FORM NO. COMMONNA FOR POLICY SCHEDULE OF NAMES AND ADDRESSES. PREM BLD COVERAGE COVERED CAUSE RATES PREMIUMS 1 1 BUSINESS INCOME INCLUDING EKTRA BAS I C FORM 0.993 $298 EKPENSE SPECIAL l"ORM 0.058 $17 LIMIT OF INSURANCE: $30,000 DEDUCTIBLE: NONE COINSURANCE: NONE MONTHLY LIMIT OF INDEMNITYt l/3 FORMS APPLICABLE TO THIS COVERAGE PART: II, 04 15 l/87 CP 00 90 7/88 CP 00 10 lO/90 CP lO 30 10/90 CP 00 30 lO/90 . ' CFCOVERG 1/86 PAGE 2 LAST ISSUED 10/lV93 ..,.,..' J I . ".(J-.tJ. fI ~ P,e.iden! DONEGAL e~ M'ARIETTA, PENNSYLVANIA 17~47.0J02 ~tI..Jl'll:.; VL'L' il.l:.I l.Ut" 1 DONEGAL MUTUAL INSURANCE CO. RT Ul, BOX 302 MARIETTA, PA 17547 COMMERCIAL PACKAGE POLICY FORMS INVENTORY POLICY NUMBER CPP 0106229 Ol RENEWAL OF CPP 0106229 00 RENEWAL NAMED INSURED; RICHARD & MARY SWARTZ POLICY LEVEL FORMS: IL 02 46 6/89 IL 09 10 1/81 IL 00 17 11/85 ZZ 4 5/80 COMMONNA 1/86 COMMERCIAL PROPERTY FORMS: IL 04 15 l/87 CP 00 90 7/68 CP 00 10 10/90 CP 10 30 lO/90 CP 00 30 10/90 COMMERCIAL CRIME FORMS: CR 10 00 1/86 CRCOVSCH l/86 CR 00 04 1/86 IL 00 17 11/85 IL 02 46 6/89 GENERAL LIABILITY FORMS: CG 24 07 11/85 CGL COY 1/86 CGLSCHED 1/86 CG 00 01 11/68 IL 00 21 11/65 FORM NO. FORMSINV 1/86 ISSUED 10/15/93 OUNEtSAL e~ MARIETTA, PENNSYLVANIA 17M7.0102 ..'......1'11... VI. L' ;.\..1.:. ~V.l.-l \ DONEGAL MUTUAL INSURANCE CO, RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL GENERAL LIABILITY CLASSI~ICATION SCHEDULE POLICY NUMBER CPP Ol06229 01 RENEWAL OF CPP 0106229 00 POLICY AMENDED, CHANGING COVERAGE EFFECTIVE: FEB. 24, 1994 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CARE~ULLY, NAMED INSURED: RiCHARD & MARY SWARTZ LOC ST TER CODE l PA Ol2 16814 RESTAURANTS - WITH NO WITHOUT DANCE FLOOR PREMOP MINIMUM PREM. PREMIUM BASIS PER 100,000 GROSS SALES 1000 SALE O~ ALCOHOLIC BEVERAGES - RATE $1.633 $0.603 PREMIUM COY $163 0 $60 P FOR CLASS: $ll9 PRODCO MINIMUM PREM. ~OR CLASS: $284 LOC ST TER CODE 2 PA Ol2 16814 RESTAURANTS - WITH NO WITHOU'l' DANCE FLOOR PREMIUM BASIS PER o GROSS SALES 1000 SALE O~ ALCOHOLIC BEVERAGES - RATE $1.940 $0.716 PREMIUM COY $0 0 $0 P ADDITIONAL FOR COVERAGE MINIMUM: $224 P COY P IS FOR PRODUCTS-COMPLETED OPERATIONS, AND COY 0 IS FOR ALL OTHER HAZARDS. " r : ' ~ ' ". ' ~" ' : 1". : t . ,I' .. '1'-. I' CGLSCHED 1/86 ISSUED 03/1i/94 oa~~ PreSldenl DONEGAL (J~ MARIETTA, PENNSYLVANIA' 7M7.0302 HUMI:: Un'l CI:: CUllY . . DONEGAL MUTUAL INSURANCE CO. RT 441, BOX 302 MARIETTA, PA 17547 COMMERCIAL PACKAGE POLICY FORMS INVENTORY POLICY NUMBER CPP Ol06229 Ol RENEWAL OF CPP Ol06229 00 POLICY AMENDED, CHANGING COVERAGE EFFECTIVE: FEB. 24, 1994 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NAMED INSURED: RICHARD & MARY SWARTZ THE FOLLOWING fORMS HAVE BEEN DELETED FROM THE POLICY. COMMERCIAL PROPERTY FORMS: CP lO 30 lO/90 D ~ r-- >G U,J~-R <Jv A (1" - W c.....f . 1 ~ . ~~ ,c;... I' ~\ J f'...- ) ~ v..- I ~ . ~. I I ~ ........ , ) <:..> (""- t.11 -~ I v... "". ~ (.' " ~ rj D - INDICATES FORM HAS BEEN DELETED FORM NO. FORMSINV 1/86 ISSUED 03/15/94