HomeMy WebLinkAbout03-3777COURT OF COMMON PLEAS
NOTICE OF APPEAl.
FKO,~
JUDICIAL DISTRICT
DISTRICT JUSTICE JUDGMENT
NOTICE OF APPEAL
Notice is given that the appellant has filed in the above Court of Commo~ Pleas an appeal from the judgment rendered by the District Justice on the
dote and in the case mentlom~ belo~
ONEBEACON INSURANCE COMPANY f/k/a CGU INSURANCE COMPANY DJ Clement, DC 09-1-01
c/o ~a~o and Margle, P.C. 107 North Co~erce Way Bethlehem PA 18017
~ ~~,~ 1 ~4 ~I E -~-J~ -' '
7/16/03 ONEBEACON INSU~CE COMPANY f/k/a I ~ DG S'r~ iNC. d/b/a
~CGU INSU~NCE COMPLY ~ NICK'S 114~
LT ~ Ron~ ~u~orney for Appellant
This bMck will be ~g~ ONLY ~n this ~ti~ is requi~ u~r P~ R.C.RJ.P. ~ /f a~t ~S CLAIMANT (S~ ~. ~.C.~.J.P. NO.
1~8~
~Js ~tke of A~al, w~ ~ei~ by t~ District Justice, wi~J ~erate as ~ ?00; (~)Jm
~PERSEDEAS ~ t~ ]~t ~ possessi~ in th;s case PILf A OOMPLAINI
filJmg DiS NOFICf
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
(This section of form to be used ONLY when appellant was DEFENDANT (see Pa. R.C.P.J.P. No, 1001(7) in action before District Justice.
IF NOT USED, detach from copy of notice of appeal to be sen, ed upon appellee).
PRAECIPE: To Prothonotary
Ente~ rule upon
(Common Pleas Nc:
, appellee(s), to file a complaint in this appeal
) within twenty (20) days after service of rule cx, suffer entry of judgment of non pros.
S~ of appeSent or h~s att~71ey or age~t
RULE: TO , ~(s).
(1) Y~ am ~ ~t a m~ Js h~ ~ u~ ~u ~ file a c~aint in ~is a~al wi~in t~ty (20) ~s a~ t~ da~ of
~vke of ~is m~ ~ ~ ~ ~s~l s~v~e ~ ~ ce~ified ~ ~Js~d ~L
(2) ff ~ do ~t fi~ a c~aint wit~n this ti~, a JU~ OF NON P~S WILL ~ E~ERED AGAINST YOU.
(3) ~ ~ of ~vke of this rule if smv~ ~s ~ ~il is ~ da~ of ~ili~
AOPC 312-90
COURT FILE TO BE FILED WITH PROTHONOTARY
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF: CUM]3ERLAND
M.g. O,,~. b9 - 1 - 01
DJ Name: Hen
~ES A. CLEMENT, JR.
Ad~.~s: 400 BRIDGE ST~ET.~'*~ .... -~
O~E TO~ CO~ONS -SUITE 3
~ C~ER~, PA
r.,.¢¢,.:(717) 774-5989 17070
AMATO AND MARGLE, P.C FILE# 2027151
107 N COMMERCE WAY APT/gTE 100
COLLECTION TRUST ACCOUNT
BETHLEHEM, PA 18017
NeTlikE OF JUDGMENT/TRANSCRIPT
CIVIL CASE
PLAINTIFF: NAME and ADDRESS
FONEBEACON INS CO/ CGU INSURANCE COTM
107 N. COMMERCE WAY
C/O RONALD AMATO, ESQ.
[~ETHLEHEM, PA 18017
· VS.
DEFENDANT: ~,AME a,-~ AC:,~ESS
F-NICK'S 114 CAFE
114 BRIDGE STREET
L
Docket No.: CV- 0000184- 03
Date F ed: 4/29/03
THIS IS TO NO'~IFY YOU THAT:
Judgment:
[] Judgment was entered for: (Name)
[] Judgment was entered against: (Name)
FOR DEF~IDAt%~ -
in the amount of $
.00 on:
(Date of Judgment)
~ Amount of Judgment Subject to
AttachmentJ42 Pa.C.S. § 8127 $
~ Portion of Judgment for physical
damages arising out of residential
lease $
Defendants are jointly and severally liable.
Damages will be assessed on:
This case dismissed without prejudice.
(Date & Time)
Amount of Judgment $ .00
Judgment Costs $ .00
Interest on Judgment $ . .00
Attorney Fees $ o 00
Total $ o 00
Post Judgment Credits $
Post Judgment Costs $
Certified Judgment Total $
ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT BY FILING A NOTICE
OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON PLEAS, CIVIL DIVISION. YOU
MUST INCLUDE A COPY OF THIS NOTICE OF JUDGMENT/TRANSCRIPT FORM WITH YOUR NOTICE OF APPEAL.
EXCEPT AS OTHERWISE PROVIDED IN THE RULES OF CIVIL PROCEDURE FOR DISTRICT JUSTICES, IF THE JUDGMENT HOLDER
ELECTS TO ENTER THE JUDGMENT IN THE COURT OF COMMON PLEAS, ALL FURTHER PROCESS MUST COME FROM THE COURT
OF COMMON PLEAS AND NO FURTHER PROCESS MAY BE ISSUED BY THE DISTRICT JUSTICE.
UNLESS THE JUDGMENT IS ENTERED IN THE COURT OF COMMON PLEAS, ANYONE INTERESTED iN THE JUDGMENT MAY FILE
A REQUEST FOR ENTRY OF SATISFACTION WITH THE DISTRICT JUSTICE IF THE JUDGMENT DEBTOR PAYS IN FULL, SETTLES,
OR OTHERWISE COMPLIES WITH THE JUDGMENT.
I certify that this is a true and correct copy of the record of the proceedings containing the judgment.
Date , District Justice
My commission expires first Monday of January, 2008 .
AOPC315-03 DATE PRINTED: 7/17/03 12.'49.'58 PM
SEAL
PROOF OF SErViCE OF NOTICE OF APPEAL AND RULE TO F~LE COMPLAINT
AF~t~AV T ebb, 'p,e or ~frm ~h~t I served
i NOTARIAl- SEAL
~I~OF~REY 6 $CHOElirAGI[
Notary
My Commission ~xplmS ~ar zu, ~w.,
COMMONWEALTH OF PENNSYLVANIA
COURT OF COMMON PLEAS
JUDICIAL DISTRICT
NOTICE OF APPEAL
FRO,~
DISTRICT JUSTICE JUDGMENT
NOTICE OF APPEAL
Notice is given that the appedlant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice on the
date and in the case mentioned belo~.
ONEBEACON INSURANCE COMPANY f/k/a CGU INSU~CE CO~y DJ Clem~v~t, DC 09-1-01
c/o ~ato and Margles P.C. 107 North C~erce Way Bethlehem PA [8017
7/I6/03 ~E ~ f/k/a 11~ BRIDG~ STREETs INC. d/b/a
LT- , R '
. on~~ ~ui~Ctorney for Appellant
Th~1008~b~ck ~1 ~ ~ O~Y ~ th s ,~;;~ is ~uimd u~ P~ R.C~OR ~ ~ ~ ~s CLAI~A~Y (s~ ~ ~.C.~.J.~.
This ~e of A~aL w~ mcei~d by t~ Dis~kt Justice, wifi ~e~ as a
~PERSEDEAS ~ ~ ]u~me~ f~ ~sses~ ~n ~is case
Signature of Prothonotary or Deputy
No.
I O01 (6) in action before District Justice, he MUST
FILE A COMPLAINT within twenty (20) days after
filing his NOTICE of APPEAL.
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
('rh~s section of'fora3 to be used ONLY when aPPellant was DEFENDANT (see Pa. RC.RJ.R No. 1001(7) in action before D/strict Justice.
IF NOT USED, detach from cop)/of notice of appeal to be sen/ed upon appellee).
PRAECIPE: To Prothonotary
Entre rule upon ~/.~/~ ~Y "~' ~
, a~,~e~.q~.p~:~r~ this
(Common Pleas Nc~ ) within twenty (20) days after service of'rule or suffe~ ent~gment of non pros.
RULE: To , appellee(s).
(1) Yo,~ am notified that a rule is hereby efltered upon you to file a' complaint in this e~ within twenty,(20) days ~ date of
service of this rule upc~ you by personal seevice or by cedified or registeeed mail -
(2) If you da not file a complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU.
(3) The date of service of this rule if service was by mall is the date of mailing.
AOPC 312-90 COURT FILE
"~'~'= POSTMARK OR DATE
RETURN
SERViCE C~mR~ ~:~
Bridge Street, Inc.
d/b/a Nick's 114 Caf~
114 Bridge Street
New Cumberland, PA 17070-2123
PS FORM 3800
jF~~_U_N~.~/'~tTE~ RECEIPT FOR CERTIFIED MAIL
..~RV/I~.
~ POSTMARK OR DATE
RETURN RI~I~ICIJO OF.U~RV FF..E
RECBPT C~MirlEO ee~
8/6/2003 Code: 2027151
2:24 PM F,le:
DJ Charles A. Clement, Jr.
District CouA 09-1-01
400 Bridge Street, ~3
New Cumberland, PA 17070-1927
PS FORM 3800
~UN/TEDS'T~TES; RECEIPT FOR CERTIFIED MAIL
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a General Accident
Insurance Company of America
Plaintiff
VS.
114 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendam
: No. 03-3777 Civil
: CIVIL ACTION
NOTICE
YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE
CLAIMS SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN
TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED BY
ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEYS AND
FILING IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE
CLAIMS SET FORTH AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO
SO THE CASE MAY PROCEED WITHOUT YOU AND A JUDGMENT MAY BE ENTERED
AGAINST YOU BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY
CLAIMED IN THE COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED
BY THE PLAINTIFF. YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTS
IMPORTANT TO YOU.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Court Administrator
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013-3387
(717) 240-6200
AMATO AND MA/~7~E, P.C.
Ronald Amato
Attorney ID #32323
Attorneys for Plaintiff
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY :
f/k/a CGU INSURANCE COMPANY :
d/b/a General Accident :
Insurance Company of America :
Plaintiff : No. 03-3777 Civil
.
VS.
114 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
CIVIL ACTION
Defendant(s) :
COMPLAINT
The above Plaintiff brings this action against the above Defendant to recover
the sum of $7,229.37, with interest thereon as hereinafter stated, upon the following cause of
action:
1. The Plaintiff, ONEBEACON INSURANCE COMPANY f/k/a CGU
INSURANCE COMPANY is located at 436 Walnut Street, Philadelphia PA 191063703.
2. The Defendant, 114 BRIDGE STREET, INC. d/b/a NICK'S 114 CAFE is
located at 114 Bridge Street, NEW CUMBERLAND PA 17070-2123.
3. A true and correct copy of a Statement of Defendant's Account is attached
hereto, made a part hereof, and marked Exhibit "A".
Count I
(Workers Compensation policy #H183281)
4. At the special instance and request of Defendant, Plaintiff issued its Workers
Compensation policy of insurance, policy number H183281, naming Defendant as the
insured, a true and correct copy of which is attached hereto, made a part hereof and marked
Exhibit "B".
5.
The above policy became operative and in full force and continued as such
until later canceled, the respective dates of issuance and cancellation are more fully described
in attached Exhibit "B".
6. Pursuant to the terms and conditions of policy number H18328! Defendant
was required to pay earned premiums calculated on Defendants total employee payroll during
the premium term.
7. By virtue of the foregoing earned premiums in the mount of $15,654.00 was
determined to be due Plaintiff from Defendant, all of which were calculated in accordance
with the rates set forth in said above policy of insurance.
8. Defendant has failed to pay earned premiums in the amount of $1,302.27.
9. Plaintiff has performed and complied with all terms and conditions required
under said above policy of insurance.
10. Plaintiff is entitled to receive interest on the above amount determined by
applying the statutory interest rate of 6.00% per annum to the past due balance. As of
August 8, 2003 the total amount of interest due to plaintiff is $113.89.
11. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set
forth above, from August 8, 2003 on down to the date of judgment in this matter.
12. The Plaintiff has made demand against the Defendant for the aforesaid sum,
but Defendant failed or refused to pay the same or any part thereof.
WHEREFORE, Plaintiff demands judgment against the Defendant for $1,416.16
together with the continually accruing interest charge at the statutory rate of 6.00% per
annum from August 8, 2003, and cost of suit.
Count II
(Commercial policy gR665385)
13. At the special instance and request of Defendant, Plaintiff issued its
Commercial policy of insurance, policy number R665385, naming Defendant as the insured,
a true and correct copy of which is attached hereto, made a part hereof and marked Exhibit
14. The above policy became operative and in full force and continued as such
until later canceled, the respective dates of issuance and cancellation are more fully described
in attached Exhibit "C".
15. Pursuant to the terms and conditions of the policy Defendant was required to
pay earned premiums.
16. By virtue of the foregoing earned premiums in the amount of $38,192.00 was
determined to be due Plaintiff from Defendant, all of which were calculated in accordance
with the rates set forth in said above policy of insurance.
17. Defendant has failed to pay earned premiums in the amount of $5,344.91.
18. Plaintiff has performed and complied with all terms and conditions required
under said above policy of insurance.
19. Plaintiff is entitled to receive interest on the above amount determined by
applying the statutory interest rate of 6.00% per annum to the past due balance. As of
August 8, 2003 the total amount of interest due to plaintiff is $468.00.
20. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set
forth above, from August 8, 2003 on down to the date of judgment in this matter.
21. The Plaintiff has made demand against the Defendant for the aforesaid sum,
but Defendant failed or refused to pay the same or any part thereof.
WHEREFORE, Plaintiff demands judgment against the Defendant for $5,813.21
together with the continually accruing interest charge at the statutory rate of 6.00% per
annum from August 8, 2003, and cost of suit.
COUNT HI
Alternative to Counts I & II - Unjust Enrichment
22. Plaintiff incorporates the allegations of every paragraph enumerated above of
this Complaint as if said paragraphs were fully set forth here at length.
23. The goods, wares, merchandise, and/or services, described in the exhibits
attached hereto were purchased by Defendant, and Defendant received and accepted the
benefit of such goods, wares, merchandise, and/or services provided by Plaintiff.
24. At all times material hereto, Defendant was aware that Plaintiff was providing
the aforesaid goods, wares, merchandise, and/or services to Defendant, and that Plaintiff
expected to be paid for such.
25. At all times material hereto, Defendant, with the aforesaid knowledge,
permitted Plaintiff to provide and/or deliver said goods, wares, merchandise, and/or services,
and to incur damages.
26. At all times material hereto, Defendant was unjustly enriched by retaining the
benefit of receiving said goods, wares, merchandise, and/or services without paying Plaintiff
fair and reasonable compensation.
27. By reason of the aforesaid unjust enrichment of Defendant at Plaintiff's
expense, an implied contract exists between Plaintiff and Defendant, and Defendant is
obligated to pay Plaintiff the quantum meruit value of the value of the goods, wares,
merchandise, and/or services described in the exhibits attached hereto, in the amount of
$6,647.18.
WHEREFORE, Plaintiff demands judgment against Defendant for $6,647.18 together
with the continually accruing interest charge at the statutory rate of 6.00% per annum from
August 8, 2003, costs of suit and all other relief to which Plaintiff may be justly entitled.
AMATO AN,~,I~ARGLE, P.C.
Ronald Amato
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(610) 866-0400
VERIFICATION
I, Michael Kennedy, Esquire, hereby state that I am the attorney-in-fact for
Plaintiff in this action and, as such, am authorized to make this verification on behalf of Plaintiff
as their verification cannot be obtained within the time allowed for filing, that the statements of
fact made in the foregoing complaint are true and correct to the best of my knowledge,
information and belief based upon the information and docu.mentation provided by Plaintiff. I
understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section
4904, relating to unswom falsification to authorities.
~f~quire
(Formerly CGU Insurance)
Nick's 114 Caf~
114 Bridge Street, Inc.
114 Bridge Street
New Cumberland PA 17070-2123
OneBeacon Insurance
Premium Collection
P.O. Box 1760
Phila., Pa. 19105-t760
Account NO.:0D5ETX
D&B#: 208909770
Date: 02/19103
Statement Of Account
Effective Policy # Policy # Service
Date Description R665385 H183281 Charliles Balance
4/17/00 4/17/00 Renewal $22,799.00 $22,799.00
6/15/00 Payment 153,799.82 $18,999.18
6/21/00 6/21/00 ~,dditional Premium Endorsement $100.00 $19,099.18
7/6/00 7/6/00 Return Premium Endorsement /$100.00) $18,999.18
7/12/00 Payment ($2,111.02 $16,888.16
8/8/00 Payment ($2,112.02 $14,776.14
10/10/00 Payment ($4,221.04 $10,555.10
11/28/00 Payment ($4,221.04 $6,334.06
2/6/01 'Payment ($4,223.04 $2,111.02
3/2/01 3/29/01 Renewal $37,778.00 $39,889.02
3/5/01 3/5/01 Renewal $7,462.00 $47,351.02
3/5/01 3/5/01 Surcharge $271.00 $47,622.02
3/5/01 3/5/01 Return Premium Discount ($247.00) $47,375.02
3/15/01 Service Charge $5.00 $47,380.02
4/9/01 Service Charge $5.00 $47,385.02
4/12/01 3/29/01 Flat Cancellation $37,778.00) $9,607.02
4/30/01 Payment ($8,444.08) $1,162.94
4/30/01 Payment 152,505.32 ($10.00 ($1,352.38)
5/14/01 Refund $6,333.06 $4,980.68
6/5/01 6/5/01 Return Premium Discount ($216.00 $4,764.68
6/5/01 6/5/01 Audit Return Premium ($4,241.0G $523.68
6/5/01 6/5/01 Surcharge ($135.001 $388.68
6/5/01 6/5/01 Audit Additional Premium $7,168.00 $7,556.68
6/5/01 6/5/01 Surcharge $221.00 $7,777.68
6/7/01 3129/01 Reinstatement $37,778.00 $45,555.68
6/7/01 3/29100 Audit Additional Premium $414.00 $45,969.68
6/7/01 Payment ($6,333.06) $39,636.62
6/8/01 Service Charge $5.00 $39,641.62
6/11/01 6/11/01 Additional Premium Endorsement $4,654.00 $44,295.62
6/11/01 6/11/01 Return Premium Discount ($159.00) $44,136.62
6/11/01 3/29/01 Surcharge $168.00 $44,304.62
6/28/01 Payment ($3,943.24 $40,361.38
6/28/01 Payment ($2,710.56 ($5.00) $37,645.82
7/9/01 Service Charge $7.00 $37,652.82
8/8/01 Late Fee $35.00 $37,687.82
8/8/01 Service Charge $7.00 $37,694.82
8/23101 Payment ($2,467.52 ($14.00) $35,213.30
9/10/01 Late Fee $35.00 $35,248.30
9/10/01 Service Charge $7.00 $35,255.30
Ired By: A. Bleiler ~
Ict: Gary Hartwell
~sion: 3021 Page: 1 ~ j~. Nick's 114
Con
Ex'ten
Cafe
{Formerly CGU Insurance)
Nick's 114 Cafe
114 Bridge Street, Inc.
114 Bridge Street
New Cumberland PA 17070-2123
OneBeacon Insurance
Premium Collection
P.O. Box 1760
Phila., Pa. 19105-1760
Account No.:0DSE7X
D&B#: 208909770
Date: 02/19/03
Statement Of Account
Effective Policy # Policy # Service '
Date Description R665385 H183281 Charges Balance
10/9/01 Late Fee $35.00 $35,290.30
10/9/01 Service Charge $7.00 $35,297.30
10/11/01 Late Fee $35.00 $35,332.30
10/24/01 Payment $10,387.04/ $24,945.26
10/24/01 Payment ($2,432.52 ($14.00 $22,498.74
11/8/01 Late Fee $35.00 $22,533.74
11/8/01 Service Charge $7.00 $22,540.74
12/10/01 Late Fee $35.00 $22,575.74
12/13/01 Late Fee $35.00 $22,610.74
12/13/01 Service Charge $7.00 $22,617.74
12/14/01 Payment ($1,279.27 1514.00) $21,324.47
1/7/02 Late Fee $35.00 $21,359.47
1/8/02 Late Fee $35.00 $21,394.47
1/8/02 Service Charge $7.00 $21,401.47
1/21/02 Payment ($8,649.7~ $12,751.72
1/21/02 Payment ($2,509.54 ($7.00) $10,235.18
1/31/02 Late Fee $35.00 $10,270.18
2/8/02 Service Charge $7.00 $10,277.18
2/27/02 2/22/02 Pro Rata Cancellation ($3,599.00 $6,678.18
6/20/02 3/29101 Additional PremCum Endorsement $406.00 $7,084.18
6/20/02 3/29/01 Return Premi~im Discount ($807.00 $6,277.18
6/20/02 3/29/01 Audit Returml~emium ($12,116.00) ($5,838.82
6/20/02 3/29/01 Surcharge ($439.00) ($6,277.82
6~20~02 3/29/01 Audit Additional Premium $12,600.00 $6,322.18
6/20/02 3/29/01 Surcharge $442.00 $6,764.18
6/21/02 2122102 ~,udit Return Premium ($75.00 $6,689.18
7/22/02 Waive Service Charges ($35.00 $6,654.18
8/8/02 3129102 Pro Rata Cancellation $0.00 $6,654.18
9/9/02 Waive Service Charges ($7.00 $6,647.18
Balance Due Company $5,344.91 $1,302.27 $0.00 $6,647.18
Prepared By: A. Bleiler
Contact: Gary Hadwell
Extension: 3021
Page: 2 Nick's 114 Cafe
CGU
. WC O0 O0 0lA
WORKERS COMF
'rNSTAL-NATZC-H
t PRODUCER CODE ISSUED BY NCCI COMPANY NO.
S7-96145 GENERAL ACCZDENT ZNSURANCE CO. OF ANERZCA lOSS9
INSURED IS CORPORATTON
~ATION AND EMPLOYERS LIABILITY
INSURANCE POLICY
INFORMATION PAGE
POLICY NUMBER POL'I~ SYMBOI~ J~KI
Q P (02) Hla 52 az
REX NUMBER ODaE7X I PREVIOUS POLICY NUMBER C P
PRODUCER
1. THE INSURED AND MAILING ADDRESS
FEDERAL T.D. ~5-174029b
NZCK'S 114 CAFE
114 eRZD~E STREET, ZNC. T/A
11e, BR13reE STREET
NE# O,IN~ERLAND, PA 17071
HER CUM~ERLAN~ AGENCY, 1'NC
S16 BRZD~E STREET, PO ~OX 510
HEN CUNBERLAND; PA 17070
Other workplaces not shown above:
2. The policy period is from, es/zg/o1 to es/2e/e2 at 12:01 A.M. at the insured's mailing address.
3,A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: PEru.
3.B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our
liability under Part Two are; Bodily Injury by Accident $ leo,oeo each accident
Bodily Injury by Disease $ zoo,oeo each employee
Bodily Injury by Disease $ soo,ssa policy limit
3.C. Other States Insurence= Part Three of the policy applies to the states, if any, listed here: ALL EXCEPT STATES PEa S~
ABOVE, N~; ON, NA, ~q/~ NY ·
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,
SEE ATTACHED SCHEDULES
Total [~tlmt~ Standard Premium
Premium Discount (If Applicable)
Expeme Ccx.'~mnt PENNSYLVANZA /SS
IF INDICATED BELOW, INTERIM ADJUSTMENT~ OF PREMIUM SHALL BE DEPOSIT PREMIUM TOTAL ESTIMATED PREMIUM e 7,48&. 00
SEMI- [] GLIARTERLY [] MONTHLY Minimum Premium ~ar~. O0
["-]ANNUALLY ~ 7~86.00 PENN~YLVANZA
ENDORSEMENTS (FORM NUMBER)
~/C000404; WCST031OB.. S127520399.* WCOO040&, G126520594, e148671098; NC370601,
W(.$70&02, WCST060SA
SCHEDULES 801
03/02/01 ~r e122oo
COUNTERSIGNED BY:
0:1 I 501
37
(AUTHORIZED REPRESENTATIVE)
Pap I G28021 (05-97)
CGLI
SCHEDULE OF OPERATIONS
ZNSTAL-HA~ZC-N
I:SCHEDULE NUMBER
01-$7-00-001
PRODUCERCODE
I SCHEDULE EFFECTNE DATE
03/29/01
Ik~$UED BY
GENERAL ACCI'DENT ZN~UEANCE CO. OF ANERZCA
ATTACHEDTO POLICY NUM:SER
(02) H18:52 81
NCCI COMPANY NO. ~
10~69
I
NAME Of INSURED & STATE LOCATION
PRODUCER
FEDERAL Z.D. 2A-1740296 NEW CUHBERLAND AGENCy; ZNC
NZCK'S 114 CAFE LOCATION OF OPERATIONS
114 BRZDOE STREET, ZNC. T/A
PENMSYLVANTA
PEHN. BUR. Y.O. 000287011S
RESTAURANT. N.O.C. 097! -2~0 :5.S9 7,BS?
INCREASED LZNZTS EHPLOYERS LZABZLZTY ;( '~L.~.t~\~0
NONE
ADDZTZONAL HEDZCAL Z HONE
TOTAL PREHZUH SUBJECT TO EXPERZENCE HOD.~FZCA EON 7;BE7
APPLZCABLE EXPERZENC:E HODZFZCATZON .B6:5
PREHZUN ADJUSTED BY APPLZCATZOfl OF EXPEREENC HODZFZC kTZO# 7;277
APPLZCABLE SCHEDULE HODZF'rCATZOfl NONE
PRENZUfl ADJUSTED BY APP~ZCATZON OF SCHEDULE K)DZFZCAT ;(gql NONE
OTHER PREHZUH CHARGES NONE
LOSS CONSTANT NONE
TOTAL ESTZHATED All, UAL STAI~ARD PREHZUH 7;R77
PREHZUH DZ$COUflT; ZF APPL'rCABLE $.4 X (247)
TOTAL ESTZHATED PREHZUH 7;0:50
PENNSYLVANZA EMPLOYER ASSESSMENT (CLASS B9S8 5.7, 271
TOTAL ESTZHATED COST 7;:501
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED,
ISSUE DATE
05/02/03, J
011 BO1 37 G28023 (11~)
SERVZCE OFFTCE COPY
CGU
i
WC O0 04 06
WC
PREMIUM DISCOUNT ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated.
The premium for this policy and the policies, if any, listed in item 3 of the Schedule may be eligible for a discount. This
endorsement shows your estimated discount in item 1 or 2 of the Schedule. The final calculation of premium discount will be
determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not
subject to premium discount.
1. State
$oh®clul®
Estimated Eligible Premium
First Next Next
$5,000 $95,000 $400,000
PENNSYLVANIA 0.0 10.9 12.6
Balance
1~.~
2. Average percentage discount= %
3. Other policies:
4. If there are no entries in items 1, 2 and 3, of the Schedule see the Premium Discount Endorsement attached to your policy
number=
POLICY NUMBER: H18 .%2 81 5 SERVICE OFFICE COPY
CGU
WC O0 04 04
WC
(4-~4)
PENDING RATE CHANGE ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date
is indicated.
A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates
shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date.
If only one state is shown in Item 3.A of the Information Page, this endorsement applies to that state. If more than One state is
shown there, this endorsement applies only in the state shown in the Schedule.
Schedule
S~te PENNSYLVANIA
WC 37 03 [OB
WC~B~o
EXCLUSION OF EXECUTIVE OFFICERS ENDORSEMENT--PENNSYLVANIA
The executive officers named in the Schedule have exercised their right to waive workers compensation and employers liability
benefits payable under this. policy. The premium basis for this policy does not include the remuneration of such persons. The
insurance carrier is entitled to reimbursement from the employer for any benefits paid under this policy for any of the persons
listed in the Schedule.
Only officers with an ownership interest in a Subchapter S corporation or officers individually having at least a 5 percent ownership
interest in a Subchapter C or sewe voluntarily and without remuneration in a non-profit corporation are eligible.
$OHEDULE
Name of Officer Social Security Office
Number Held
Type of %
Optional Signature Corp. Ownership
($,C or V) Interest
#ZLLZAH NZCHOLS
NZCK NZCHOLS
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
POLICY NUMBER: H18 $2 81 5 SERVZCE OFFTCE COPY
CGLI
WORKERS COMF ~SATION AND EMPLOYERS LIABILITY
.,~SURANCE POLICY
COMMISSION ADVICE
'rNSTAL -NATZC-H
ICOMML.eSION ADVICE EFFECTIVE DATE
IISSUED BY
gENERAL ACCEDENT ZNSUIRANCE CO. OF AltER'rCA
POLICY NUMBER ~
Q P (02) HZS $2 81
lOsBgNCCICOMPANY NO. I
PRODUCERCODE
POLICY PERIOD:FROM 0~,'29/01 TO 03/29/02
NAME OF INSURED AND MAILING ADDRESS
FEDERAL E.D. ~K-Z7402:g&
NECK'S 114 CAFE
114 BRZDGE STREET, ZNC. T/A
114 BRZDGE STREET
NE#CUMBERLAND, PA 17070
PRODUCER
NE# CUHBERLAN/) AGENCY, /NC
516 BRZDGE STREET, PO BOX $10
NEW CUHBERLAND, PA 17070
COflHESSTOH ADVTCE
NeNNN CONMESSZON RATE ?.0Z TOTAL COHHZSSZOfl DUE 4~S2:2.5~*,. NffNea
STATE
*** EXPLANATION OF COMMISSION ***
TOTAL AVERAGE
COMMISSION COMMISSION
PREMIUM RATE
COMMISSION
AMOUNT
ALL OTHER 07~462.00 7.0Z
TOTAL 07,462:.00 7.0Z
THE COH~ZSSXON SCALE ZS APPLXED TO STANOARD PREHXUfl (BEFORE ADdU~llIENT
FOR PRENZUfl DXSCOUNI', ZF ANY) APPLZCABLE XN THE VAR/OU~ STATES. THE
AVERAGE COHHXSSZOH RATE /S APPLECABLE TO TH/S TRANSACT/ON ANO TO ALL
FUTURE TRANSACTIONS~ UNTZL THE NEW AVERAGE RATE OF COHH/SS/Ofl ZS DEVELOPED
AT THE TXNE OF F/HAL AUD/T. REFER ALL GUEST/OHS REGARDZIqlG TH/S COHHZSS/ON
ADV/CE TO YOUR UNBERWRZTER.
ISSUE DATE
05/02:/0!
32:
01 I
SOl 57
SERVTCE OFFTCE COPY
G28024 (1 !
CGU
WORKERS COMP. ~a. TION AND EMPLOYERS LIABILITY
INSURANCE POLICY
ENDORSEMENT
03/29/01
ATTACHED TO POLICY NUMBER
Gl P ¢02) HIS S2 lB].
NCCl COMPANY NO,
ENDORSEMENT NUMBER
pRODUCER CODE
B7-9614S
POLICY PERIOD~ FROM
ENDORSEMENT ~.FF~.~:¥iVE DATE
IISSUED BY
GENERAL ACC/DENT ENSURANCE CO. OF AHER'rCA
05/29/01 TO 0:5/29/02
at 12~01 A.M. AT THE INSURED'S MAILING ADDRESS
THE INSURED AND MAILING ADDRESS
FEDERAL X.D, 2S-1740296
NZCX'S 114 CAFE
114 SRZDOE STREET; I:NC. T/A
114 SRZCOE STREET
NE# CUI'BERLAND, PA 17RTR
PRODUCER
NENCUMEERLAN~ AGENCY; ZNC
S16 BRZCOE STREET; PO BOX 510
NEll CI~ERLAND; PA 17071
ZIISTAL-IMTZG-H
ZN COHSXDERATZOfl OF ADD/TXOIML PREHZUfl DUE R4;66S.RO
XT XS AGREED THAT THE POLXCY XS AHENDED AS FOLLOffSz
CLASS eg?s ( ) 2NS.R1 ST.BT(PEHH. ) LOC.RO :TS AHEHDED TO READs
$.S9 34S,11R R12,5~9.80
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
[ ~SSUE DATE ]
06/08/01 COUNTERSIGNED BY:
U~UTHORIZED REPRESENTATIVE)
o&/ee*/OX 22144 01 I SOX $7 G28022(11-88)
SERVICE COPY
NsuRANCE
INSTALLMATIC DATE PAGE NO.
WORKERS' COMPENSATION PREMIUM AUDIT INVOICE ~ONTHLY 86/:L9/0~' 1
ARRi_~LiR~ :OXBOROUBH~I111 ~7-9E, 145 ~0E87R~)[5 46 RUDIT OD~'ETX
t P (~) HI8 ,3~ 81 ~ ~$/~9/0! ~/~'9/0;' ~/:=*=J/$:l. 3129/02 /
NICI(~S 114 CAFE
114 BRII:)SE STREET, INC. T/R
114' BRTI)(~E t~TREET
NEkl CUNSERL.~ND~ PPi 17070
NEN CUNBERL.RND INaURRNCE
PO BOX 31Et
NEH CUPli~ERLRNO P'A 17070
sTRTE OF I:~E'NN~YLvI~INIR
0975 ~E~TRURRNT
PREIqIUM SUB3ECT TO EXP'ERXENCE HODIFxcRTxoN
APPLICR~.E ExPERI~ MODXFXCRT~ON
PREMIUM ADJ*U~TED lSY t:IPPL. ICI:YT*XON: OF EXPERIENCE
TOTRL ERRNE~ STRNDRRD PRENILIN
PRENII.~ DISCOUNT 6. 5Y,
PENNBYLVRNIR HC ENII~.OYER R~BE~r4ENT
EXPENSE CONgTRNT
STRTE TOT;IL
REVISED COMMISSION ADVICE (RESULT OF AUDIT)
Commlasle~ ia calculated based on the commiasion scale and premium before premium dis~ount,
applicable in the various states. The average Commission Rate shown is applicable to the Total Policy
Commission premium. Please refer ail questions regarding this Advice to
YOUR UNDERNR ZTER
IMPORTANT TO AGENT: A~ltional Premiums having been fully earned are due and should be
paid immedlete~. Fletum Premi _u~'~ sh~u~ Id _not_.be paid until ell outs~dtng
06/'t9/~;~ 82866 ~
3~9~ 099 3. 59 Ia, 8=J~:
[FICATION
(807)
3.75',( 442
teE,
:t2~ 235
~ 1 co,,,.~as~'r.o.
1~', 235.
12, 1 ~.9.'0~
NICKs9 114 DqFE
114, BRZD~E t~TREETe INC.
11,4 BRIDSE 5TREET
NEN CUMBERL..RND,, I:~ 1787e
NEN CUMSERLRND I:ISKYs ][NC
NEN CUMBERLAND PR 17e70
B'r~TE TOTRL
REVISED'~'MMISSION ADVICE (RESULT OF AUDIT)
Commlsalon la calculated baaed on the commission scale and premium before premium dl~ount,
applicable In the various states. The average Oommlsalon Rate shown le applicable to the Total
Policy Commission premium. Please refer all questions regarding this Advice to
YOUR UNDERWRZ TER
IMPORTANT TO AGENT: Additional Pmmlumu hiving been fully eamed are due and should
)e p~)~l~t~)tYl: R~tu~.rn;~P~lUl~li~'h~ld n°~lPaid until ell outeten~ premium, ere ed.lu~ted.
BRANCH OFFICECOPY
376, i
PENNSYLrANIA COMPENSATION R.-.YING BUREAU
EXPERIENCE RATING CALCULATION
QP02H185281 2870015
N~Cl~ I1~ CAFE POLICY NU#SER rILE NO,
114 423 3/29/01
N~H CI.T~ER[,A~iD PA 17070 C[]~ERLAm)(:O. CARe. EE~ DT 0~ RATI~
POLICY L~,SES AS REPO~O LOSSES AS USED
YE~ INDE~ITY MEDICAL TOTAL (A)
98 a28 a28 a28
P~T l
E~IBIT 0F
A~UAL LOSSES
TOTAL 428 428 428
POLICY CLAZH ~LT. tYPE LOSSES ~ LOSSES AS
YE~ ~MBER A~. ENd* REPORTED USED
P~T ~
E~BZT 0F LOSSES
SUBdE~ TO
VALUES ISSUE DATE
TOT~ 2/02/0]
*? - DEAT~ ; ~ - pERN TOTAL:3 - MAd0R; 4 - M;NOR: ~ - TEHPOWY
CL~$ POLZCY PAYROLLS EXPECTED EXPECTED ~T~RZZED ~THOR~ZED
CODE YE~ LOSS FACTOR LOSSES (E) CLOSES RATZ~ VALUE:
953 .29
97 18~,261 2.13 3,925
98 200,~ 1.86 3,728
99 314,7~2 1.~9 ~,690
975 699,~51 12,3~3 975 2.78
P~T
E~IBIT
OF
PAYROLLS,
EXPECTED
LOSSES,
~T~RIZED
CLOSES
~D
RATI~
VALUES
PART IV - RATING PROCEDURE
i CTUAL LOSSES
A 428
i XPECTEO LOSSES CREDIBILITY LIMIT CHARGE I.OO0-C
E12,343 C .060 L*C .021 .940
EXP. MOD
.963
GENi ~L ACCIDENT INSURANCE COMPANY OF AM~ i
100 CORPORATE CENTER DRIVE
POBOX8$51
CAMP HILL PA 17001-8851
NOTICE OF NONRENEWAL OF INSURANCE
Named Insured & Mailing Add.s:
NICK'S 114 CAFE
114 BRIDGE STREET INC T/A
114 BRIDGE STREET
NEW CUIVtBERLAND PA 17070-2123
Producer: 3796145
NEW CUMBERLAND AGENCY', INC
516 BRIDGE STREET, PO BOX 310
NEW CUMBERLAND PA 17070-0000
Policy No.: QPH183251
Type of Policy: WORKERS' COMPENSATION
Date of Expirafien: 03/29/2002; 12:01 A.M. Local Time at the mailing address of the Named Insured.
We will not renew this policy when it ~xpires. Your insurance will cease on the Expiration Date shown
The reason for nomenewai is POTENTIAL HAZARDS AND EXPOSURES ASSOCIATED WITH THIS
RISK, MATERIAL TO THE INSURABILITY, ARE UNACCEPTABLE.
You may request we provide you information about losses under this policy and previous policies, which
we imve issued to you, nottoexcced~hrceYcers. You most makeyour wriRen request within 10 days
from the receipt of this notice. We will provide the infonnafion to you within 30 days from the date
we receive your request.
NICK'S 114 CAFE
114 BRIDGE STREET INC T/A
114 BRIDOE STREET
NEW CUMBERLAND PA 17070-2123
Date Mailed:
18th day of January,2002
Authori~d Con~eny Representative
PACN26NONE APP
ODEN3.0.01.09a Copy for Branch Office 01042002MYN
FORM# CN969701PA51995 Pag~ 1 of I
~J£1~l:l~)~k )~..~..Ik/£1~ J I~[,. )/~r~l~I' ¢..U. (.)1- AMERICA
A Stock Company, Boston, Massachusetts 0~2108-3100
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
NAMEDINSUP, F. DandMAIEN~AODHESS:
NICK'S 114 CAFE
114 BRIDGE STREET INC. T/A
114 BRIDGE STREET
NEW CUMBERLAND, PA 17070-2125
BUS/NESS:
RESTAURANT/BAR
TRANS~qlON:
PREV POM~)'
REX NUM~I~
RENEWAL
APR6653850000
OD5ETX
03/01/2001
FORMOFBIISINEGE: CORPORATTON
POLICYPEIIIGD: From 03/zg/zo01 to 03/Z9/ZOOZ at 12:0! A.M. Standard Timeat your mailing address.
in return for the payment of the premium, and subject to all terms of this policy, we agree with you to provide the insurance stated in this policy.
COVERAGE PARTS awl SUPPLEMENTS . pGEMIIMP
COMHERCIAL PROPERTY COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
COHMERCIAL CRIME COVERAGE PART
TOTAL ANNUAL PREMZUH
t4,660.00
t10,076.00
$Z2,885.00
#157.00
$37,778.00
PREMIUM SHOWN IS PAYABLE ON INSTALLMATIC MONTHLY PLAN
* This premium may be subject to adjustment.
The above numbered .policy is completed by the use of these common declarations and the applicable coverage part declarations,
together with the common policy conditions, coverage form(s) and forms and endorsements, if any.
NAME and AD§J~SS OF ~ COUNTE~ ~':
(Authorized Representative)
(Data)
G66966 (Ed. 6-94)
OFFICE~ C~ HARRISBURG
C
CE OFFICE COPY'
Page o1 of OS
RK[ NUMBER~ HEHO7 0 26185001
CGLI
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
GENERAL ACCIDENT IN" ~ANCE CO. OF AA4ERIC~.
A Stock Company, Boston, Massachusetts 02108-3100
NAMED/ATSi/JlED
NZCK~S 114 CAFE
PREMISES BUILDING
NO. NO.
00001 001
O000g 001
OCCUPANCY ADOREES
RESTAURANT
THREE FAMZLY DWELLZN
114 BRZD6E STREET
NEW CUMBERLAND, PA Z7070-Z123
122-124 BRID6E STREET
NEW CUMBERLAND, PA 17070
G66968(Ed. 6-94) SERVZCE OFFZCE COPY Page e2 of os
OFFICE~ C~JI I~I~R1'SBUi~~ FILE NUMBER~ HEHI? O 26].65001
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
GENERAL ACCIDENT INS ,~NCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02108-3100
QPR665585 103/01/2001
NAMED INSURED
NICK'S 114 CAFE
The following is a listing of the declarations forms, and endorsements which form your complete policy
INTERLINE FORMS;
ZLOOZ71185 COMMON POLICY CONDITIONS
ZL09100181 PENNSYLVANIA NOTICE
6107790588 EXECUTION OF OFFICERSt SIGNATURES
1L01721195 PA.CHANGES
1L09550898 EXCL.OF CERT.COMP.RELATED LOSSES
6150920599 POLICY HOLDER NOTICE
ZL02460500 PA. CHANGES - CANC. AND NONRENEWAL
ZL01660199 PENN. CHNGS.- ACTUAL CASH VALUE
ZL02460498 PENNSYLVANIA CHGS-CANCL & NON-RENEWAL
ZLOOZlO49B NUCLEAR ENER6Y LZAB EXCL (BROAD FORM)
PROPERTY 'FORM COVERAGES:
CP00900788 COMMERCIAL PROPERTY CONDITIONS
CP01860486 CHANGES-POLLUTANTS
CP00100695 BUILDING AND PERSONAL PROPERTY
CP10500695 CAUSES OF LOSS-SPECIAL FORM
G155140500 CGU CP COV AMENDMENTS EXT ENDT
G155250S00 C6U CP SEC FOR PROPERTY EXT ENDT
CP00500695 BUSINESS INCOME &EE OTHER
LIABILITY FORM COVERAGES~
L29510195
C024070196
6108170796
6141550996
L29290995
CG04S10998
CGZO110196
C$20261185
CG11470798
6155530500
G155430500
CG00010798
CG00S31095
CRIME FORM COVERAGES:
CR00041090
CR10000497
EXCLUSION-LEAD LIABILITY-PA
PROD/COMP OPERATIONS HAZARD REDEFINED
HIRED & NON-OWNED AUTO LZAB.
POLICYHOLDER*NOTIFICATION-COIl47
EXCLUSION - ASBESTOS LIABILITY
YR 2000 COMPUTER RELATED LTD. COV$.
MANAGERS OR LESSORS OF PREMISES
DESIGNATED/PERSON ORGANIZATION(CLASS)
EMPLOYMENT RELATED PRACTICES EXCLUSION
POLICYHOLDER NOTICE
BRIDGE ENDORSEMENT
COMMERCIAL GENERAL LIABILITY COVGE FORM
LIQUOR LIABILITY COVERAGE FORM
THEFT DISAPPEARANCE & DESTRUCTION
CRIME GENERAL PROVISIONS - LOSS SUS
ZSO COPYRIGHT, INSURANCE SERVICES OFFICE, INC., 198S, 1984,
1988, 1989, 1990, 1991, 1992, 1995, 1994.
COPYRIGHT, COMMERCIAL UNION INSURANCE COMPANY,
1985, 1986, 1987,
1992
G6697a(Ed. 6-94) SERVICE OFF[CE COPY Page os ofo$
OFFICE: ~ HARRTSBURG FILENUMBER~ FIEFIO? O 261~$001
GENERAL ACCIDENT IN, ~.ANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02108-31OO
COMMERCIAL ACCOUNT POLICY
COMMERCIAL PROPERTY
COVERAGE PART DECLARATIONS
NAMEZI/NS//IIED
NICK'S 110, CAFE
COVERAGE(S)
PREM~ESNO. BUIL~NGNO. PREMISESNO. BUILDING NO.
00001 001 00002 001
BUILDINg
LIMIT OF INSURANCE:
DEDUCTIBLE:
COINSURANCE:
OPTIONAL COVERAGES:
REPLACEMENT COST:
COV AMEND ENDT:
SEC FOR PROP ENDT:
COVERED CAUSE OF LOSS:
BASIC gROUP I
DASIC gROUP IZ
SPECIAL
PENS PROP-INSD
LIMIT OF INSURANCE:
DEDUCTIBLE;
COINSURANCE=
OPTIONAL COVERAGES:
REPLACEMENT COST:
COVERED CAUSE OF LOSS:
BASIC gROUP I
BASIC gROUP II
SPECIAL
SPECIAL THEFT OTH INCREM
BIgEE OTHER
LIMIT OF INSURANCE:
DEDUCTIBLE:
COINSURANCE:
OPTIONAL COVERAGES:
COVERED CAUSE OF LOSS:
BASIC gROUP Z
BASIC gROUP ZZ
SPECIAL
BZ&EE RENTAL
LIMIT OF ZNSURANCE~
DEDUCTZBLE~
COINSURANCE:
OPTIONAL COVERAGES=
COVERED CAUSE OF LOSS:
BASIC gROUP Z
BASIC gROUP IZ
SPECIAL
SPECIAL SPECIAL
90`01,700 911S,$00
91,000 el,000
90~ 90~
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
SPECIAL
965,200
91,000
90X
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
SPECIAL
9100,000
NONE
APPLIES
APPLIES
APPLIES
DOES NOT APPLY
APPLIES
APPLIES
DOES NOT APPLY
APPLIES
APPLIES
APPLIES
DOES NOT APPLY
DOES NOT APPLY
SPECIAL
912,000
IOOX
NONE
APPLIES
APPLIES
APPLIES
Page 01 of Ol
FILE NUMBER: HEN07 0 26185001
G66969 (Ed. 6-94)
SERVICE OFFICE COPY
OFF}CE= C~*U HARRTSBURG
Commercial Pro~rty
P0384 11 96
RESTAURANT SELECT PLUS COVERAGE
This endorsement modifies insurance provided under the following=
BUILDING AND PERSONAL PROPERTY COVERAGE FORM
COMMERCIAL PROPERTY CONDITIONS
SCHEDULE*
Premlm No.
Premium
$ Thc1 uded
CoverM~e Extemlom
Umlts of L. Personal Pmperb/of Your Customers and $ 10,000
Insumme Guests
A. Newly Acquired or Constructed Property$500,000 M. Recharging of Kitchen Fire Suppmesion $ 1,000
Buildings Systems
Business Personal Property $250,000 N. Fine Arts $ 10,000
B. Personal Property Off Premises $ 50,000 Valuable Papers and Records Cover~ $ 15,O00
C. Personal Property in Transit $ 10,000 Accounts Receivable Coverage $ 25,000
D. Outdoor Properly $ 10,000 EDP Cover~
E. Personal Property of Employees $ 10,000 Electronic Date Processing "Hardware" $ 15,000
F. Recharging of Fire Extinguisher $ 2,000 Electronic Date Processing "Date" and $ 15,000
G. Arson Reward $ 5,000 "Media"
H. Beck-up of Sewers and Drains $ 10,000 "Extra Expenses" $ 10,000
I. Inventd~y or Appraisal Cost $ 2,500 Food Spoftsle Cover~
J. Computer Virus $ 2,500 Part I $ 10,000
K. Personal Effects $ 5,000 Part II $ 10,000
* Information required to complete this Schedule,
When this endorsement Is attached to the policy, insurance
provided under the Commemlal Property Coverage Part is
extended to provide the coverage described in this endorse-
ment to the premises listed in the Schedule above. This
coverage is subject to the provisions applicable to the Building
and Personal Property Coverage Form. The applicable Causes
of Loss Form and the Common Policy Conditions of this policy
except as provided below.
COVERAGE EXTENSIONS
A. Paragraph A.5., Coverage Exten~ons of the Building and
Personal Property Coverage Form is deleted in its entirety
and replaced by the following:
5. Coverage Extensions
In addition to the Limits of Insurance, you may extend
the insurance provided by this policy as provided
below.
Except as otherwise provided, the following Exten-
sions apply to property located in or on the building
described in the Schedule above or in the open (or in
a vehicle) within 100 feet of the described premises.
a. Newly Acquired or Constructed Property
(1) You may extend the insurance that applies
to Building to apply to;
(e) Your new buildings while being built on
the described premises~ and
If not shown on this endorsement, will be shown In the Declarations
(b) Buildinp you acquire at locations, other
than the described premises, intended
for:
(I) Similar use as the building
described in the Doclaratlons= or
(11) Uses as a warehouse.
The most we will pay for loss or damage
under this Extension is $500,000 at each
building.
(2) You may extend the insurance that applies
to your Business Personal Property to apply
to that property at any location you acquire
other than at fairs or exhibitions.
The most we will pay for lose or damage
under this Extension is $250,000 at each
building.
(3) Insurance under this Extension for each
newly acquired or constructed property will
end when any of the following first occurs;
(a) This policy expires;
(b) 30 days expire after you acquire or begin
to construct the property= or
(c) You report values to us.
We will charge you additional premium for
values reported from the date construction
begins or you acquire the property.
b; Pe~onal Proporty Off Premises
You may extend the insurance that applies to the
Buildlngand Personal Property Coverage Form to
your covered Property other than "stock", that is
temporarily at a location you do not own, lease
or operate.
This extension does apply to Covered Property=
(1) In or on a vehicle.
(2) In the care, custody or control of your
selespereon= or
(3) At any felt or exhibition.
The most we will pay for loss or damage under
this Extension is $10,000.
c. Pe~onal Property In Transit
You may extend the insurance that applies to
Business Personal Preporty to apply to covered
Business Personal Property, other than "money"
and "securities", while It is in the course of
transit. The most we will pay for loss or damage
under this Extension is $10,000.
d. Outdoor Pmpe~y
You may extend the insurance provided by the
Building and Pe~onsl Property Coverage Form to
apply to your outdoor fences, radio a nd television
antennas, (including setellite dishes), signs
(other than signs which are attached to build-
ings,) trees, shrubs and plants, (other than
"stock" of trees, shrubs or plants), including
debris removal expense, caused by or resulting
from any of the following causes of lose, if they
are Covered Causes of Loss:
(1) Fire;
(2) Lightnlng~
($) Explosion;
(4) RIot or Civil Commotion; or
(5) Aircraft.
The most wa will pay for loss or damage under
this Extensloo is $:[0,000, but not more than
$500 for any one tree, shurb or plant. These
limits apply to any one occurrence, regardless of
the type or number of items lost or damaged in
that occurrence.
a. Personal property of Employees
You may extend the insurance that applies to
Business Personal Property to apply to personal
property owned by your employees while such
property is located:
(1) In or on the buildings at the described
premises or in the open (or in a vehicle)
within IOO feet of the premisesz or
I Fe~m No! P03841
(2) Elsewhere in the performance of "your
work".
The most we will pay under this extension for all
loss or damage in any one occurrence is
$10,000; but we will not pay more than $500
for loss or damage to personal property belonging
to any one person.
f. Reoha~e of Fire Extlngubhere
You may extend the insurance provided by this
policy to apply to the ~(paneas you incur for the
recharging of fire extinguishers made nece_~y
by the fighting of a fire at the premises described
in the Schedule above or adjacent to such proper-
ty.
The most we will pay under this extension for any
one occurrence is $2,000.
Arson Reward
We will reimbu~e you for an arson reward that
you give to someone who discloses Information
that leads to the conviction of a parson or persons
for arson at the premises described in the
Schedule above.
The most we will pay under this Extension is
$5,000 each occurrence.
h. Back. Up of 8ewem and Drains
We will pay for loss or damage to Covered Proper-
ty caused by or resulting from water that packs
up from s sewer or drain.
Exclusion B. 1.1~.(3) of the Causes of Loss Form
does not apply to this Extension.
The most we will pay under this Extension is
$10,000 each occurrence.
I. Inventory or Appraisal CO~
We will pay up to $2,500 each occurrence for
the ccot of any invento~y or appraisal required as
a result of direct physical loss or damage to
Covered PropeAy caused by or resulting from a
covered cause of Ices.
J. Computer Virus
We will pay:
(1) Your expenses to extract a "computer virus"
from covered electronic data processing
"hardware", "date" and "media"; and
(2) The expenses you incur to restore such
"hardware", "date" and "media" to their con-
dition prior to the "loss", or the cost to
replace such property, whichever is less.
These expenses must be a result of direct physi-
cal "loss" from a "computer virus" that occurs
and becomes known to you during the policy
period. We will only pay these expan~ if you
report them to us within 180 days of the date of
the direct physical "loss".
The most we will pay under this Coverage Exten-
sion in any one occurrence is $2,500.
This coverage is the only portion of this policy
that provides coverage for a "computer virus"
"loss", regard less of any other cause or event that
contributes concurrently or in any sequence to
the "loss",
k. Personal Effects
(1) You may extend the insurance that appiise
to your Business Personal Property to per-
sonal effects owned by you, your partners or
officers. This extension does not apply to loss
or damage by theft.
(2) If there is any other insurance covering the
same loss or damage, insurance under this
coverage extenion does not apply.
I. Personal Property of Your Customers and
Guests
(1) You may extend the insurance that applies
to Business Personal Property to personal
property belonging to your customers and
guests at the described premises.
(2) We will not pay more under this coverage
extension than the amount for which you are
· legally liable.
The most we will pay for any one occurrence is
$5~000.
m. Recha~ln~ of Kitchen Fire Supprecslon Sys.
tsms
We will pay for the expenses you incur for the
recharging or refilling of fire suppression systems,
which protect your cocking equipment, made
necessary when they discharge as intended to
control a fire or if they accidentally discharge at
the premises dsecrlbed in the Declarations.
The most we will pay for any one occurrence is
$1,000.
n. Fine Arts
We will pay up to $10,000 each occurrence for
loss or damage caused by a covered cause of loss
to your ~flna arts" and "fine arts" owned by
others in you care custody and control at the
premises described in the Schedule or Declara-
tions. We will also pay up to $5,000 each
occurrence for loss or damage caused by a
covered cause of Ioes to your"fine arts" while in
transit.
If there is not a schedule of your "fine arts" on
file with us, we will pay the appraised market
value at the time and place of the loss.
Each of these Extensions is additional insurance. The
Additional Condition, Coinsurance, does not apply to
these Extensions.
Form No: P0384
11 96
Page3 of 13 I
FOOD SPOILAGE COVERAGE
The Building and Personal Property Coverage Form is ex-
tended to provide the foliowing=
Part I -- We will pay for direct physical loss of or damage to
"perishable food stock" caused by or resulting from:
a. Compiste or partial interruption of electrical power or gas
which is supplied to your premises by a utility company.
To be covered, the interruption must be caused by physi-
cal loss of or damage to property belonging to the utility
company, including the utility company's transmission or
distribution lines or transformers, by a Covered Cause of
Loss applicable to the building at which the loss occurred.
b. Sudden and accidental electrical or mechanical break-
down of refrigeration equipment located on the described
premises.
c. Contamination of refrigerated "perishable food stock" by
refrigerant leakage caused by accidental rupture or burst-
ing of refrigeration equipment.
d. Freezing caused by the faulty operation of a stationary
heating plant located on the dsecirbed premises.
Part II -- We will not pay more than the limit shown in the
Schedule above in any one occurrence for loss of Business
Income and Extra Expense caused by direct physical loss of or
damage to "perishable food stock' covered under Food
Spoilage Part I.
e. Business income means the=
(1) Net Income (Net Profit or Loss before income taxes)
that would have been earned or incurred= and
(2) Continuing normal operating expenses incurred, in-
cluding payroll~
b. The amount of Business Income loss will be determined
based on=
(1) The Net Income of the business before the direct
physical loss or damage occurrad:
(2) The likely Net Income of the business if no physical
damage had occurred, but not including any Net
Income that would likely have been earned as a result
of an increase in the volume of business due to
favorable business conditions caused by the impact
of the Covered Cause of Loss on customers or on other
busineeses:
(3) The operating expenses, including payroll expenses,
necessary to resume "operations" with the same
quality of service that existed just before the direct
physical loss or damage~ and
(4) Other relevant sources of informatior~, including=
(a) Your financial records and accounting proce-
dures;
(b) Bills, invoices and other voucherez and
(c) Deeds, liens or contracts.
c. Extra Expense means necessary expenses you incur during
the "period of restoration" that you would not have
incurred if there had been no direct physical loss or
damage to "perishable food stock'' caused by or resulting
from a Covered Cause of Loss.
(1) We will pay any Extra Expense to avoid or minimize
the suspension of business and to continue "opera-
flon$":
(e) At the descri;:~l premises; or
(b) At replacement premises or at temparary loca-
tions, Including;
(I) Relocation expanses; and
(11) Costs to equip and operate the replacement
or temporary locations.
(2) We will pay any Extra Expense to minimize the
suspension of business If you cannot continue "opera-
tlons".
(3) We will pay any Extra Expanse to repair or replace any
property to the extant It reduces the amount of loss
that otherwise would have been payable under this
endorsement.
d. The amount of Extra Expanse will be determined based
(1) AIl expanses that exceed the normal operating expert-
sas that would have been Incurred by "oporatlons"
during the "period of restoration" if no direct physical
loss or damage had occurred, We will deduct fram the
total of such expanses;
(a) The salvage valua that remains of any preparty
bought for temporary use during the "period of
restoration", once "operations" are resumed;
and
(b) Any Extra Expanse that is paid for by other
insurance, except for insurance that is written
subject to the same plan, terms, conditions and
provisions as this Irmurance; and
(2) All necessary expanses that reduce the Business
Income loss that otherwise would have been incurred.
e. Resumption of Opomtlerm
We will reduce the amount of your=
(1) Business Income loss, other than Extra Expense. to
the extent you can resume your "operations", In
whole or in part, by ~slng damaged or undamaged
property (including merchandise or stock) at the
described premises or elsewhere.
(2) Extra Expanse loss to the extent you can return
"operations" to normal and discontinue such Extra
Expanse.
f. If you do not resume "operefloes", or do not resume
"operations" as quickly as possible, we will pay based on
the length of time It would have taken to resume "opera.
tlons" as quickly as possible.
g. We will not pay for:
(1) Any increase of loss caused by or resulting from=
(a) Delay in rebuilding, repairing or replacing the
property or resuming "operations", due to inter-
feranca at the location of the rebuilding, repair or
replacement by strikers or other persons; or
(b) Suspension, lapse or cancellation of any license,
lease or contract. But If the suspension, lapse or
cancellation is directly caused by the suspension
of "operations", we will cover such loss that
affects your Business Income during the "period
of restoration".
(2) Any Extra Expanse caused by or resulting from
suspension, lapse or cancellation of any license, lease
or contract beyond the "period of restoration".
(3) Any other consequential loss.
FOOD SPOILAGE EXCLUSIONS
A. Only the following Exclusions of the Causes of Loss Form
apply to the Food Spoilage coverage:
1. B.l.b., Earth Movement~
2. B.l.c.,GovemmentAotion;
3. B.l.d., Nuclear Hazard~
4. B. 1.L,War and MIIItaryAction;and
$. B.l.g., Water.
B. The following Exclusions are added=
We will not pay for loss or damage caused by or resulting
from any of the following:
1. The deactivation of electrical power caused by the
manipulation of any switch or other device used to
control the flow of electrical power or currant.
2. The disconnection of any refrigeration equipment
from the source of power by you or any of your
employees.
3. Shortage of foal'used for the oparation of a stationary
heating plant which services the described premises.
4. Explosion of steam boilers, steam pipes, steam tur-
bines or steam engines owned or leased by you or
operated under your control.
5. Breaking of any glass that is a permanent part of any
refrigeration equipment.
6. The inability of a power source at the described
premises to provide sufficient power due to lack of
generating capacity to meet demand.
7. The inabllfty of an Electrical Utility Company or other
power source to provide sufficient power due to=
(a) Lack of fuel~ or
(b) Governmental order.
VALUABLE PAPERS AND RECORDS COVERAGE
A. With respect to this coverage only, Section A., Coverage,
of the Building and Personal Property Coverage Form is
deleted and replaced by the following=
We will pay for direct physical "loss" to Covered Property
caused by or resulting from any of the Covered Causes of
Loss.
1. Covered Property, as used in the Valuable Papers
and Records coverage, means the following type of
property that is your property, or property of others in
your care, custody or control;
Valuable papers and records, meaning inscribed,
printed or written=
a. Documents;
b. Manuscripts; and
c. Records
including= abstracts, books, deeds, drawings, films,
maps, or mortgages.
But v~luable papers and records does not mean=
d. "Money' or "Securities';
e. Electronic data processing "date" a nd "media".
2. Property Not Covered
Covered Propart7 does not include;
a, property held es samples or for delivery after sale;
b. Property in storage away from the premises
shown in the Schedule above; or
c. Contraband, or property in the course of illagel
transportation or trade.
$. Covered Causes of ~
Covered Causes of Loss means Risks of Direct Physi-
cal 'Lms" to Covered Property except those Causes
of "L-'~--'' listed in the Exclusions.
4. Additional Coverege-- Collapse
a. We will pay for direct physical "loss" to Covered
Property, caused by collapse of a buildinl~ or any
· part of a building scheduled in this endorsement,
if the collapse is caused by one or more of the
following:
(1,) The "specified caum of loss" or breakage
of building glass, all only as insured ageinst
in this policy,
(2) Hidden decay;
(3) Hidden Insect orvermin damage;
(4) Weight of people or personal property;
(5) Weight of rain that collects on a roof;
(6) Use of defective material or methods in con*
structlon, remodeling or renovation if the
collapse occurs during the course of the
construction, remodeling or renovation.
However, if the collapse occurs after con-
struction, remodeling or renovation is com-
plete and is caused in part by a cause of
"1o~" listed in 4.a.{1,) through 4.a. (5), we
will pay for the "loss" even if use of defective
material or methods in construction,
remodeling or renovation, contributes to the
collapse.
b. If the direct physical "less" does not involve
collapse of a building or any part of a building,
we will pay for'k~" to Covered Property caused
by the collapse of personal property only if:
Form No~ P0384
11 961
Page 5 of 13
(1) The personal property which collapses is
inside a building scheduled in this endorse-
ment; and
(2) Thecollapsewascaused bye causeof"less"
listed in 4.s.(1) through 4.a.(6) above.
c. Collapse does not include settling, cracking,
shrinkage, bulging or expansion.
This Additional Coverage does not increase the Limits
of insurance for Valuable Papers and Records
provided in this endorsement.
5. Coverage Extension -- Removal
if you give us written noticewithin 10 days of removal
of your covered valuable papers and records because
of imminent danger of "loss", we will pay for "loss"
while they are=
a. At a safe place away from the described
premises~ or
b. Being taken to and returned from that place.
This Coverage Extension is included within the Limit
of Insurance applicable to the Valuable Papers and
Records Coverage.
B. Additional Conditions
1. Paragraph f. of the Valuation Loss Condition in the
Building and Personal Property Coverage Form does
not apply to valuable papers end records that are
actually replaced or restored.
2. Insurance Under Two or More Coverages
The following is added to paragraph C. Insurance
Under Two or More Coverages Common Policy Con-
dition:
If a Coverage Form or Endorsement Is attached to this
policy that provides coverage for any of the extensions
orcoverages provided by thie endorsement, the limit
shown In the schedule and the coverage provided by
thie endorsement are deleted and replaced by the
limff and coverage provided by the other Endorse-
ment or Coverage Form.
ACCOUNTS RECEIVABLE COVERAGE
A. With respect to this coverage only, Section A., Coverage,
of the Building and Personal Property Coverage Form is
deleted and replaced by the following=
1. We will pay=
a. All amounts due from your customers that you
are unable to collect,
b. interest charges on any loan required to offset
amounts you are unable to collect pending our
payment of these amounts=
c. Collection expenses in excess of your normal
collection expanses that are made necessary by
'10""; and
d. Other reasonable expanses that you incur to
re-establish your records of accounts racaivable;
Form Noz P0384
1]'96
P~Sof la
that result from direct physical "1o~" caused by or
resulting from any of the Covered Causes of Loss to
your records of accounts receivable located at the
premises described in the Schedule above.
2. Propen'y Nee Covered
Coverage does nee apply to..
a. Records of accounts receivable in storage away
from the premises shown in the Schedule
above=or
b. Contraband or property In the course of illegal
transportation or trade.
3. Covered Cause~ of ~
Covered Causes of Loss means Risks of Direct Physi-
cal "Lees" to your records of accounts receivable
except those Causes of "L~es" listed in the Exclusions.
4. Additional Coverage -- collapse
a. We will pay for direct physical "loss" to Covered
Property caused by collapse of a building or any
part of a building scheduled in this endorsement,
if the collapse is caused by one or more of the
following..
(1) The "speclflnd cause~ ee I~" ~r breakage
of butldlng ~lees, all only as insured against
In this policy,
(2) Hidden decay=.
(3) Hidden Insect orvermln damage=
(4) Weight of people or personal property;
(5) Wel~,flt of rain that collects on a roof,
(6) Use of defective material or methods in con-
structlon, remodeling or renovation if the
collepee occurs during the course of the
construction, remodeling or renovation.
However, if the collapse occurs after con-
struction, remodeling, or renovation is com-
plete and Is caused in part by cause of loss
listed in 4.a. (1) through 4.a. (5), we will pay
for the"le~" even if use of defective material
or methods in construction, remodeling or
renovation, contributes to the collapse.
b. If the direct physical "1~" does not involve
collapse of a building or any part of a building,
we will pay for"le~' to Covered Property caused
by the collapse of personal property only iff
(1) The personal property which collapses is
inside a building scheduled in this endorse-
ment~ and
(2) The collapse was ceused by a cause of"lo#"
listed in 4,a,(1) through 4,a.(6) above,
c, Collapse does not Include willing, cracking,
shrinkage, bulging or expansion.
This Additional Coverage does not increase the Limits
of Insurance for Accounts Receivable provided in this
Endorsement.
5. Coverep Extension -- Removal
If you give us written notice within ].0 days of removal
of your records of accounts receivable because of
imminent danger of "lm~", wewill pay for "1~" while
they are:
a, At a safe place away from the described
premises;
b. Being taken to and returned from that place.
This Coverage Extension is included within the Limit
of Insurance applicable to Accounts Receivable
Coverage.
B. Additional Conditions
I. The following is added to peregreph 7. Valuation, of
Section E. Loss Conditions in the Building and Per-
sonal Property Coverage Form:
a. If you cannot accurately establish the amount of
accounts receivable outstanding as of the time of
"lo~", the following method will be used=
(1) Determine the total of the average monthly
amount of accounts receivable for the 12
months immediately preceding the month in
which the "le~' occurs; and
(2) Adjust that total for any normal fluctuations
in the amount of accounts receivable for the
month in which the "le~' or demaae oc-
curred or for any demonstrated variance from
the averege for that month.
b. The following will be deducted from the total
amount of accounts receivable, however that
amount Is establiahed~
(1) The amount of the accounts for which there
is no #10~";
(2) The amount ee the accounts that you are able
to re-establish or collect;
(3) An amount to allow for probable bed debts
that you are normally unable to collect; and
(4) All unearned Interest and service charges.
2, Paragraph $, Recovered Property, of Section £. ~
Conditions In the Building and Personal PropeAy
Coverage Form is deleted and replaced by the follow-
ing:
You will pay us the amount of all recoveries you
receive for a "lo#" paid by us. But any recoveries in
excess ee the amount we have paid belongs to you.
3. Insurance Under Two o~ Mom Covera~
The following is added to the Insurance Under Two
or More Coveragex Common Policy Condition:
If any Accounts Receivable Endorsement is attached
to this policy, covere~e provided under this endorse-
ment is deleted and replaced by the Accounts Receiv-
able.
ACCOUNTS RECEIVABLE AND VALUABLE PAPERS AND
RECORDS EXCLUSIONS
A. Exclusions Applicable to Accounts Receivable and Valu-
able Pape~ and Records Coverages
1. Only the following Exclusions of the Causes of Loss
Form apply to Accounts Receivable or Valuable
Papers and Records Coverages provided under this
endorsement=
a. B.l.c., Governmental Action=
b. B. 1.d.,NuclearHazard= and
c. B.l.f., War and Military Action.
2. The following Exclusions ara added=
a. We will not pay for *loss" caused by or resulting
from any of the following. But if "loss" by a
Covered Cause of Loss results, we will pay for
that resulting "loes".
(1) Weather conditions. But this exclusion only
applies If weather conditions contribute in
any way with a cause or event excluded in
paragraphs A.1, A.2, or A.3. above to
produce the "1o~"
(2) Acts or decisions, includingthefailura to act
or decide, of any person, group, organization
or governmental body.
(3) Faulty, Inadequate or defective=
(a) Planning, zoning & developing, survey-
ing, siting~
(b) Design, specIfications, workmanship,
repair, construction, renovation or
remodeling, grading, compection=
(c) Materials used in repair, construction,
renovation or remodeling or
(d) Malntenance~
of part or all of any property on or off the
described premises.
b. We will not pay for "loss" caused by or resulting
from any of the following=
(1) Dishoneat or criminal acts by you, any of your
partners, employees, directors, trustees,
authorized representatives or anyone to
whom you entrust the property for any pur-
pose=
(a) Acting alone or in collusion with othera~
or
(b) Whether or not occurring during the
hours of employment.
This exclusion does not apply to acts of
destruction by your employees, but theft by
employees is not covered.
This exclusion does not apply to a carrier for
hire.
(2) Delay, Ioesof use, Iossof marketoranyother
consequential Iow.
Form No= P0384 I
11 961
Pa~ 7 of 13 J
(3) Electrical or magnetic injury, disturbance or
erasure of electronic recordings.
But we will pay for direct "loss" caused by
lightning.
(4) Voluntary parting with any property or
records of accounts receivable by you or
anyone entrusted with the property if in-
duced to do so by any fraudulent scheme,
trick, device or false pretense.
(5) Unauthorized instructionstotransfer proper-
ty to any person or to any place.
(6) Collapse, except ea provided under Addition-
al Coverage -- _Co. ilapee.
B. Exclusions Applicable to Acc~)unts Receivable Coverage
Only
1. We will not pay for "loss" caused by or resulting from
any of the following=
a. Alteration, falsIfication, concealment or destruc-
tion of records of accounts receivable done to
conceal the wrongful giving, taking or withhold-
ing of "money", "securltlec" or other property.
This exclusion applies only to the extent of the
wrongful given, taking or withholding.
b. Bookkseping, accounting or billing errors or omis-
sions.
2. We will not pay for "loss" that requires any audit of
records or any inventory computation to prove its
factual existence.
C. Exclusion Applicable to Valuable Papers and Records
Coverage Only
1. Wewill not pey for"loss" caused by or resulting from
errors or omissions in processing or copying.
But we will pay for direct "loes" caused by resulting
fire or explosion If these causes of loss would be
covered by this coverage.
2. Wewill not pay for"loes" caused by or resulting from
wear and tear, gradual deterioration or latent defect.
EDP COVERAGE
A. Coverages
With respect to this coverage only, Section A., Coverage
of the Building and Personal Property Coverage Form is
deleted and replaced by the following=
1. Electronic Data Proceesing Property Coverage Sec.
tion
We will pay for direct physical "loss" to Covered
Property resulting from any of the Covered Causes of
Loss and for which a Limit of Insurance is shown in
the Schedule,
a, Covered Property, as used in the Electronic Data
Processing Propeffy Section, means the following
types of property for which a Limit of Insurance
is shown In the Schedule,
Be
(I) Electronic data processing "hardware" used
in your business which=
(a) You own~ or
(b) is property of others in your care, cus-
tody or control. But such property is not
covered for more than the amount for
which you are legally liable.
(2) Electronic data processing "data" and
"modlaa used in your business which=
(a) You own, or
(b) is property of others in your care, cus-
tody or control. But such property is not
covered for more than the amount for
which you ars legally liable.
b. We will cover the property while It
(1) At a premises shown in the Schedule above;
(2) In transit to or from your premises~ and
($) Temporarily at other premises.
2. Extra Expenm Coverale Section
s. We will pay the actual and neceesa~y "Extra
Exponm" you Incur in order to continue your
data proceasin8 operations during the "period of
restoration" because of direct physical "lin" to
Covered Property caused by or resulting from any
of the Covered Causes of alma.
Such direct physical "lin" must occur during the
Policy Period at a premises listed in the Schedule
b. Covered Property, as used in the aExtra Expert-
m" Coverage Section, means:
(1) The electronic data processing ahardware",
"data" and amedla" covered under the
Electronic Data Processing Property
Coverage Section of this Coverage Form=
(2) The building in which such ahardwsre",
"data", and #media" Is located, if the
damage prevents access to your data
processing facllity~ or
(3) The air conditioning system or electrical sys-
tem needed to operate your electronic data
processing ahan~wsm".
Property Not Covered
Covered Property does not include=
a. Accounts, bills, deeds, evidences of debt, valu-
able papers, records, abstracts, manuscripts or
other documents, unless they are converted into
adata, form and then only in that form~
b. Property which you are leasing or renting to
others while it is away from your premises]
c. Any electronic data processing "data" and
"media" which cannot PA replaced with others of
the same kind or quality= or
d. Contraband, or property in the course of illegal
transportation or trade.
I' From Noz P0384
p., of lsll 961
C. Covmed Caum of Los~
Covered Causes of Loss means Risks of Direct Physical
"Lma" to Covered Property except those Causes of "l.m~"
listed in the Exclusions.
D. Additional Coverages
1. Applicable to the Electronic Data Proceselng
Property Coverap Section
a. Prssewation of Property
If it is necessery to move Covered Property from
a premises listed in the Schedule to preserve it
from "lo~" by any of the Covered Causes of
"l.o~", we will pay for any direct physical '1o~"
to that property~
(1) While it is being moved or while temporarily
stored st another premisea~ and
(2) Only if the alma OCCUrs within 30 days after
the property is first moved.
The Limit of Insurance for Property in Transit
or Temporarily at Other Premises does not
apply to this Additional Coverage.
This Additional Coverage does not increase
the Limits of Insurance provided by this
endorsement for EDP coverage.
b. Debris Removal
(1) We will pay your expense to remove debris
of Covered Property caused by or resulting
from s Covered Cause of "Le~" that occurs
during the policy period. The expenses will
PA paid only if they ere reported to us in
writln~ within [80 days of the earlier of:
(a) The date of direct physical "1~' or
damsgel or
(b) The end of the policy period.
(2) The moat we will pay under this Additional
Coverage is 25% of..
(a) The amount we pay for the direct physi-
cal "line" to Covered Proparty~ plus
(b) The Deduotibie in this Coverage Form.
But this limitation does not apply to any addition-
al debris removal limit provided in paragraph (4)
below.
(,t) This Additional Coverage does not apply to
costa to~
(a) Extract'pollutants" from land orwater,
or
(b) Remove, restore or replace polluted land
or water.
(4)
(a) The sum of direct physical "loss" and
debris removal expense exceeds the
Limit of Insursnca~ or
(b) The Debris Removal expense exceeds
the amount payable under the 25%
Debris Removal coverage limitation in
paragraph (2) above;
We will pay up to an additional $10,000 for
each premises in any one occurrence under
the Debris Removal Additional Coverage.
Payment under this Additional Coverage is in
addition to the EDP Coverage Limits of In-
surance.
Duplicate "Data" and "Media"
(1} We will cover duplicate and back up "data"
and "media" which is:
(a) Stored at a sepemte location at least
100 fee{ away from any of the premises
listed In the Schedule= and
(b) Not covered under another policy.
(2) Wewtll not payfor#lms"toduplicats''data"
and "media" in any one occurrence than the
lesser of the following amounts=
(a) 10% of the Limit of Insurance for a
"data" and "media" at the largest
premises shown in the Schedule~ or
~(b) $50,000.
This Additional Coverage does not apply to
property at any scheduled premises.
This Additional Coverage is in addition to the
applicable Limits of Insurance provided by
the Electronic Data Processing Property
Coverage Section.
Additionally Acquired Computer "Hardware"
(1) If during the Policy term you acquire addi-
tional computer "hardware" of a type al-
ready covered under the Electronic Data
Processing Property Section, we will cover
such property for up to 60 days. The most
wewill pey for"loss" to additionally acquired
property is the lesser of the following
amounts:
(e) 40% of the Limit of Insurance for
"hardware" at the largest location
Shown in the Schedule as of the date of
"to~"; or
(b) $100,000.
(2) insurance under this Additional Coverage
will end when any of the following first oc-
curs:
(a) This policy expires;
(b) 60 days expire after you acquire the
property~ or
(c) You report such property to us.
Form Nm P0384 I
p~ge 9 of 13~ ~. 96
You will pay the additional premium due at
pro-rata of our current rates from the date
you acquire the property,
This Additional Coverage does not increase
the applicable Limits of insurance provided
by the Electronic Data Processing Property
Coverage Section,
c, Additionally Acquired Premises
(1) If during the Policy Period you move the
Covered Property to a new premises, we will
cover the properly at such new premises for
up to 60 days. The most we will pay lot"loss"
to Covered Property at a new location is
$100,000.
(2) You will report the premises change within
60 days of such change. We have the right
to make a premium adjustment for such
premises change which may be required by
our currant rates.
If you do not report such premises change,
coverage will end 60 days after the date of the
change.
This Additional Coverage does not increase the
applicable Limits of Insurance provided by the
Electronic Data Processing Property Coverage
Section.
f. Fire Protection Devices
We will reimburse you for any necessary expense
to recharge or refill fire protection devices which=
(1) Are specifically designed to protect the
Covered Property; and
(2) Were used against a Covered Cause of
"Loss".
The most we all pay under this Additional
Coverage in any one occurrence is $50,000,
Such payment is in addition to the applicable
Limits of Insurance provided by the Electronic
Data Processing Property Coverage Section.
Applicable to the Extra Expenses Coverage Section
Civil Authority
We will pay the actual and necessary "Extra Expen-
ses'', you incur to continue your data processing
operations if you are prohibited access to the
premises where your data processing operations are
located by order of civil authority because of direct
physical "Joes" to adjacent property caused by or
resulting from any of the Covered Causes of "Loss".
This Additional Coverage will apply from the time of
such order and for up to three weeks.
This Additional Coverage does not increase the Limits
of Insurance provided by the "Extra Expenses"
Coverage Section.
3, Applicable to All EDP Coverage Sections Collapse
Collapse
e. We will pay for direct physical "loss" to Covered
Property, caused by collapse of a building or any
pert of e building at a premises scheduled under
this endorsement, if the collapse is ca used by one
or more of the following:
(1) The "specified causes of loss" or breakage
of building glass, all only as insured against
in this policy;
(2) Hidden decay;
(3) Hidden insect orvermin demaga~
(4) Weight of people or personal property;
(5) Weight of rain that collects on a roof,
(6) Useof defective metedal or methods in con-
struction, remodeling or renovation if the
collapse occurs during the course of the
construction, remodeling or renovation.
However, if the collapse occurs after con-
struction, remodeling or renovation is com-
plete and is caused in pert by a cause of
"loss" listed in 3.e(1) through $.a.(l), we
will pey for the"loss" even If use of defective
material or methods in construction,
remodeling or renovation, contributes to the
collapse.
b. If the dlreot physical "less' does not involve
collapse of e building or any part of a building we
will pay for for "Ices' to Covered Property caused
by the collapse of personal property only if~
(1) The personal property which collapses is
inside a building at a premises scheduled
under this endorsement; and
(2) Thecollapsewascaused bye cause of"lo~"
listed in 3.a.(1) through 3.a.(6) above.
c. Collapse. doss not include setting, cracking,
shrinkage, bulging or expansion.
This Additional Coverage does not increase the Limits of
Insurance for EDP coverage.
B. EDP Coverage Exclusions
1. We will not pey for "1o#" caused directly or indirectly
by any of the following. Such "loss" is excluded
rege rdless of a ny other ca use or event th at co ntributes
concurrently or in any sequence to the "loss":
e. Governmental Action
Seizure or destruction of property by order of
governmental authority.
But we will pey for 'qms' caused by or resulting
from acts of destruction ordered by governmental
authority and taken at the time of a fire to prevent
its spread if the fire would be covered under this
endorsement.
Form No,, P03,84 I
11 961
Pale 10 of 13
b. Nuclea~' Hazard
(I) Any weapon employing atomic fission or
fusion~ or
(2) Nuclear reaction or radiation, or radioactive
contamination from any other cause.
But we will pey for direct "1o~" caused by result-
ing firs if the fire would be covered under this
endorsement.
¢. War and MIIItmy Action
(1) War, including undeclared or cJvJl war;
(2) Warlike action by e military force, including
action in hindering or defending against an
actual or expected attack, by any govern-
ment, sovereign or other authority using
military personnel or other agents; or
(3) Insurrection, rebellion, revolution, usurped
power or action taken by governmental
authority in hindering or defending against
any of these.
not pey for a "lin' caused by or resulting
from any of the following:
e. Dishonest or criminal acts by you, any of your
partners, employees, directors, trustees,
authorized representatives or enyone to whom
you entrust the property for any purpese=
(1) Whether acting alone or in collusion with
others; or
(2) Whsther or not occurring dudng the hours of
employment.
This exclusion does not apply to acts of destruc-
tion by your employees~ but theft by employees
is not covered.
b. Wear and tear, any quality in the property that
causes It to damage or destroy Itself, hidden or
latent defect, gradual deterioration, depreciation,
insects, vermin, rodents.
But we will pey for direct "1o~" caused by the
Delay, loss of use, or loss of market.
Voluntary perting with any property by you or
anyone entrusted with the property if induced to
do so by any fraudulent scheme, trick, device, or
false pretense.
Unauthorized instruotions to transfer property to
any person or any place.
Theft from any unattended vehicle, except theft
which occurs during loading and unloading
operations, unless such vehicle has a fully
enclosed body or compertment and, at the time
of theft, all its windows, doors, and compart-
ments were closed and locked and there are
2. We will
visible signs on the vehicle that the theft was the
result of forced entry.
g. Theft of propertywhile it is left loaded on a parked
vehicle overnight.
Exclusions f. and g. do not apply to Covered Proper.
ty while It la In the custody of e carrier for hire.
h. Changes in your electrical power supply, includ-
ing interruption, power surge, blackout, or
brownout, if the cause of such event originates
more than 100 feet from any premises location
listed in the Schedule above.
I. Error in machine programming or instructions to
any machine.
J. "Loss" caused by of reeultingfrom the discharge,
dispersal, seepage, migration, release or escape
of "pollutants" unless the discharge, dispersal,
seepage, migration, release or escape is itself
caused by any of the "specified causes of loss".
But if the discharge, dispersal, seepage, migra-
tion, release or escape of "pellutsnt~' results in a
"specified catme of loss", we will pay for the
"loss" caused by that "specified causes of loss".
$. We will no~' pay for a "1o~' caused by or resulting
from any of the following. But ff "less" by a Covered
Cause of "Loss" results, we will pay for that resulting
I. Weather conditions. But this exclusion only ap-
plies if weather conditions contribute in any way
with a cause or event excluded in parsgreph 1.
above to produce the "1o~'.
b. Acts or decisions, including the failure to act or
decide, of any person, group, organization or
governmental body.
c. Collapse except as provided in the Collapse Ad.
dltlonal Coverage.
4. Special Exclusions
The following exclusions apply only to the Extra
Expenses Coverage Section=
We will not pay for"Ires" caused by or resulting from
any of the following;
a. Any local or state ordinance or law regulating
construction or repair of buildings.
¢. The suspension, lapse, or cancellation of any
lease, license, contract or order.
d. Interference by strikers or other persons at your
premises with the repair or replacement of
property which has been damaged or destroyed,
or with your efforts to resume operations.
C. EDP Coverage Additional Condltlor~
The following conditions apply in addition to the Common
Policy Conditions:
Form No, P0384 J
11 961
Pa~e 11 of 13 I
1. Applicable to All EDP Coverage Sections
a. The following Loss Conditions of the Building and
Personal Property Coverage Form apply to this
EDP Coverage:
(1) Paragraph E.I. Abandonment=
(2) Paragraph E.2. Appraisal;
(3) Paragraph E.3. Duties in the Event of Loss;
and
b. The following Commercial Property Conditions
apply to this EDP Coverage:
(1) Paragraph D. Legal Action Against us
(2) Paragraph F. Policy Period, Coverage Ter-
ritory
(3) Paragraph H. Policy Period, Coverage Ter-
ritory.
c. Loss Payment
We will pay or make good any "1o~" covered under
this coverage Form within 30 days after:
(1) We reach agreement with you;
(2) The entry of final judgement; or
(3) The filing of an appraisal award.
We will not be liable for any pert of a "loss" that
has been paid or made good by others.
d. Privilege to Adjust with Owner
In the event of"loss" involving property of others
in your care, custody or control, we have the right
to~
(1) Settle the "loss" with the owners of the
property. A receipt for payment from the
owners of that property will satisfy any claim
of yours.
(2) Provide a defense for legal proceedings
brought against you. If provided, the expense
of this defense will be at our cost and will not
reduce the applicable Limit of Insurance
under this endorsement.
e, Recoverlm
Any recovery or salvage on a "loss" will accrue
entirely to our benefit until the sum paid by us
has been made up.
2. Applicable to the Electronic Data Processing
Property Coverage ~ectlon
The following conditions apply in addition to the
Common Policy Conditions:
a. Valuation
In the event of a "loss" we will determine the
value of Covered Property as of the date of the
"lo~l" as follows:
(1) Electronic Data Processing "Hardware"
(a) The value of the property will be the
lesser of the following amounts:
Form No~ P03841
(I) The replacement cost of that
property without deduction for
depreciation~
(11) The cost of reasonably repairing
that properly to its condition imme-
diately before "loss"~ or
(lid The cost of replacing that property
with substantially identical proper-
ry.
In the event of a "loss", the value of the
property will be determined as of the
time of "loss".
(2) Electronic Data prOcessing "Data" and
"Media"
The value of the property will be either:
(e) Theactualcostofreproducingorreplec-
lng the lost or damaged "dlta" and
"medll", If you actually reproduce or
replace them~ or
(b) The cost to replace the blank "media"
with substantially Identical property.
3. Applicable to the Extra Expenses Coverage Section
The following conditions apply in addition to the
Common Policy Conditions:
e. Sclv~e
If you buy Property to use temporarily until your
data processing operations return to "normal",
we will subtract Its remaining value from the
"Extra F. xpeness" you have.
b. R-.umpflon of Operations
You will resume all or part of your data processing
operations es quickly as possible. We will reduce
the amount of your "io~" to the extent you can
return your operations to "normal" and discon-
tinue your "Extra Expenses".
LIMITS OF INSURANCE
A. 1. Regardless of the number of buildings at any one
premises shown in the Schedule above, the most we
will pay for loss or damage or "loss" In any one
occurrence under this endomement is the applicable
Limit of Insurance shown in the Schedule above,
except as provided below.
The Limits of insurance for the above Coverage Ex-
tensions and Coverages apply separately to each
premises listed in the Schedule above.
2. For covered valuable papers and records temporarily
away from the premises shown in the Schedule
above, the most we will pay for "loss" in any one
occurrence is I0% of the Valuable Papers and Records
Limit of Insurance shown in the Schedule above.
$. For Electronic Data Processing "hardware", "data"
and "media", the most we will pay for "loss" to
Covered Property In transit or temporarily at other
premises in any one occurrence ia $15,000.
4. For the Personal Property In Transit Coverage Exten-
sion, regardless of the number of premises covered
by this endorsement, the most we will pay for loss or
damage to under this Coverage Extension in any one
occurrence is the Limit of Insurance for Personal
Property in Transit shown in the Schedule above.
B. The Limits of Insurance for Accounts Receivable
Coverage, Valuable Papers and Records Coverage, EDP
Coverage, Food Spoilage Coverage and the Coverage
Extensions are in addition to the applicable limits under
the Building and Personal Property Coverage Form.
DEDUCTIBLES
A. Section D. Deduotlbles of the Building and Personal
Property Coverage Form Is deleted and replaced by the
following for the Coverage Extensions and Coverages
listed below:
We will not pay for loss or damage or "1~" in any one
occurrence until the amount of the adjusted loss or
damage or "loss" exceeds $250. We will then pay the
amount of loss or damage or"io~" in excess of $250 up
to the applicable Limit of Insurance for the following
Coverage Extensions and Coverages:
1. Personal Property in Transit.
2. Outdoor Property.
3. Back-Up ofscwere and Drains.
4. Computer Virus.
B. Personal Effects.
6. Fine Arts.
7. EDP Coverage.
8. Food Spoilage Coverage
B. No deductible applies to the following Coverage Exten-
sions and Coverages under this endorsement:
1. Personal Property of Employees.
2. Arson Reward.
3. Inventory or Appraisal Cost.
4. Personal Property of Your Customers and Guests.
5. Recharging of Kitchen Fire Suppression Systems.
6. Recharging of Fire Extinguisher.
7. Valuable Papers and Records Coverage.
8. Accounts Receivable Coverage.
C. The Deductible described In Section D. of the Building and
Personal Property Coverage Form applies to the Newly
Acquired or Constructed Property Extension and the Per-
sonal Property Off Premises Extension.
Additional Definitions
1. "computer Vlroses" means unauthorized intrusive
codes or programming that are entered into covered
"hardware", "data" and "media" and Interrupt your
operations at the described premises.
2. "Data" is a fact, concept or instruction that is con-
verted into a form that can be used in a data process-
lng operation. It includes computer programs but not
"media".
$. "Extra Expenses" (EDP Coverage only) means
operating expenses over and above the costs you
normally would have incurred if no "loss" had oc-
curred. This includes expenses to rant or use other
property, premises or facilities.
It does not include=
a. Loss of profits or earnings that result from a
reduction of your data processing operationsr
b. Any direct or indirect property damage that is
insurable under a property damage policy= or
c. The cost to repair or replace damaged preparty.
However, we will pay expenses in excess of the
usual cost to repair or replace such property ff
they ara necessary in order to raduce your "Extra
Expenses". We will not pay mora for such expen-
ses to repair or raplaca damaged property than
the amount by which they raduce your total
"Extra Expense" "loss".
4. "Fine Arts" means paintings, etchings, pictures,
tapestries, art glues windows, valuable rugs, statuary,
marbles, bronzes, antique fumitura, rara books, anti-
que silver, manuscripts, porcelains, rare glass, bric-a-
brac, and similar property of rarity, historical value or
artistic merit.
5. "Hardware" means equipment and components
which accepts information, process and analyze that
infOrmation according to programmed instructions,
and then produces or retains the results of those
processes.
6. "Loss" means accidental loss or damage.
7. "Media" is the material on which "data" is racorded
such as magnetic tapes, disk packs, drums, paper
tapes, cards and programs. This includes the "data"
stored on the "media".
8. "Normal" means conditions that would have existed
if no "loss" had occurred.
9. "Operations" (applicable to Food Spoilage Coverage
only) means your business activities occurring at the
described pramises.
10 "Period of restoretlon" (applicable to Food Spoilage
Coverage and EDP Coverage only) means the period
of time that=
a. Begins wffh the date of diract physical loss or
damage= and
b. Ends on the eadier of=
(1) The datawhen the property at the described
premises should be repaired, rebuilt or
11.
12.
Form No~ P0384 I
11 961
Pa&m 13 of 13 I
replaced with reasonable speed and similar
quality= or
(2) The datewhen the business is resumed at a
new permanent location.
"Period of restoration" does not include any in-
craased period required due to the enforcement of any
ordinance or law that;
(1) Regulates the construction, use or repair, or
requiras the tearing down of any property; or
(2) Requires any insured or others to test for,
monitor, clean up, remove, contain, treat,
detoxify or neutralize, or in any way raspond
to, or assess the effects of "pollutants".
The expiration date of this policy will not cut short the
"period of restoration".
"Perishable food atock*' means food products in-
tended for human consumption:
a. Maintained under controlled temperature condi-
tions for its preservation; and
b. Susceptible to loss or damage if the controlled
temperature conditions change.
"Specified Causes of Lass" (applicable to Valuable
Papers and Records Coverage, Accounts Receivable
Coverage and EDP Coverage only) means the follow-
ing: Fira; lightening; explosion; windstorm or hail~
smoke= aircraft or vehicles; riot or civil commotion;
vandalism; leakage from fire extinguishing equip-
menb sinkhole collapse= volcanic action; failing ob-
jects= weight of snow, ice or sleet; water damage.
a. Sinkhole collapse means the sudden sinking or
collapse of land into underground empty spaces
craated by the action of water on iimeatone or
dolomite. This Cause of "Loss" does not include..
(1) The cost offllling sinkholes= or
(2) Sinking or collapsing of land into man-made
underground cavities.
b. Failing objects does not include "loss", to;
(1) Personal property in the open; or
(2) The interior of a building or structure, or
property inside a building or structure, unless
the roof or an outside wall of the building or
structure is first damaged by a falling object.
c. Water damage means accidental discharge or
leakage of water or steam as the direct result of
the braaking apart or cracking of any part of a
system or appliance (other than a sump pump
including its related equipment and parts) con-
taining water or steam.
CGLJ
COMMERCIAL ACCOUNT POLICY
COMMERCIAL GENERAL LIABILITY
COVERAGE PART DECLARATIONS
GENERAL ACCIDENT INS ANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02t08-3100
NAMED INSURED
NICKr5 114 CAFE
General Aggregate Limit (Other than Products--Completed Operations)
Products--Completed Operations Aggregate Limit
Personal and Advertising Injury Umit
Each Occurrence Limit
Fire Damage (any one fire) Limit
Medical Expenses (any one person) Limit
SX,O00,O00
$500,000
~500,000
$500,000
$100,000
~5,000
ALL CLASSIFICATIONS APPLICABLE TO THIS COVERAGE FORM MAY BE FOUND IN THE ATTACHED SCHEDULES.
PRODUCTS AND COMPLETED OPERATZONS ~1,Z03.00
ALL OTHER $8,875.00
TOTAL #10,076.00
PREM BLOG nC~RiPTiONOFCLASSlRCATiOfl CLASS l SUaU~K I a,'rKaaem I EXPOSURE I ANNUAL I PREMIU&I
.o. I .o. I "~ I COOE I .... I ........ IAMOUNT I FINAL RATE I CHARGED
00001 001 RSTRNI'S-I~'rTR SALES OF ALCH BEV THAT AR 16a15 PREHI'SES PER tloeo SALES 1,s86,oeo 6.11s9 $8,4.77
LESS THAN 7SX OF THE TOTAL ANN RECEZPT
OF THE RESTAURAHTS-#'rTH DANCE FLOOR
00001 001 RSTRI4TS-#'rTH SALES OF ALCH BEV THAT AR 16815 PRODUCTS
LESS THAN 7.61 OF THE TOTAL ANN REC:E*rpT
OF THE RESTAURANTS-#I'TH DANCE FLOOR
00601 001 EHPLOYERS NON-OHNERSflZp AUTO L'IrAB 66010 SPECZAL
0-2~ E#PLOYEES
00001 001 HZRED AUTO LTABZLZTY COVERAGE 66190 SPECZAL
00001 001 HANAGERS OR LESSORS OF PREHZSES at9950 PREHZSES
00001 001 DESZGNATED/PERSOfl ORgANTZATZOfl(CLASS) 899S0 PREHZSES
00001 001 DESZGNATED PERSOI4/OROAHZZATZOO(LOCATZO at99SO PREflZSES
00001 001 DESZSHATED PERSON/OROANZZATZOfl(LOCATZO 899.60 PRODUCTS
00002 001 DffELLZNGS- THREE-FAHZLY (LESSOR'S RZSK 63.012 PREHZSES DffELLZHOS
ONLY)-TNCL PROD/COflPL OPS
PER 01000 SALES 1,586,000 0.8676 $1,205
NBR OF EHPLOYEES I 01S1
NO EXPOSURE I $97
1 117.66q8 0118
* This premium may be subject to adjustment.
G66970 (Ed. 6-94)
OFFICE~ CG~I HARRZSBURG
SERVZCE OFFICE COPY
Page Ol of ol
FILE NUMBER, flEH07 0 26185001
GENERAL ACCIDENT IN~ ~ANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02108-3100
COMMERCIAL ACCOUNT POLICY
COMMERCIAL LIQUOR LIABILITY
COVERAGE PART DECLARATIONS
0'/01/2001
NAMED/NS////ED
NXCK~S 11°, CAFE
Aggregate Limit ~1,000,000
I Each Common Cause Umit '500,000
ALL CLASSIFICATIONS APPLICABLE TO THIS COVERAGE FORM MAY BE FOUND IN THE ATTACHED SCHEDULES.
ATTACHED SCHEDULE(S) $22,885.00
TOTAL SZZ, 885. O0
PREM BLO~ I DESCRIPTION OF CLASS FICATIO~I CLASS oa'rc name EXPOSURE ANNUAL I PREMIUM
NO. NO. CODE ......... AMOUNT FINAL RATE CHARGED
00001 001 RESTAURANTS, TAVERNS., HOTELS, HOTELS - 58161 PER ~lOeO SALES 911,$00 25.115e ~2~*,68.6
XI, K;LUDXNO PACKASE SALES
* This premium may be subject to adjustment,
G66972 (Ed. 6-94)
Page aZ of O1
FILENUMaER~ I~EI~O? e 26185001
SERVICE OFFICE COPY
OFFICE~ C~U HARR'rSBURG
CGU CG 04 31 0998
YEAR 2000 COMPUTER-RELATED AND OTHER ELECTRONIC PROBLEMS --
LIMITED COVERAGE OPTIONS
This endorsement modifies insurance provided under the following~
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULES
SCHEDULE A -- COVERAGES TO BE PROVIDED (SUBJECT TO THE DESCRIPTION IN SCHEDULE B)
Check any one or more of the following:
[] Bodily Injury [] Property Damage [] Pemonal and Advertising Injury
SCHEDULE B -- DESCRIPTION OF LOCATION, OPERATIONS, PRODUCTS OR SERVICES TO BE COVERED
(TO WHICH SCHEDULE A APPLIES)
Description of location(s) operation(s), product(s) or service(s)
All locations, operations, products or services to which this policy applies.
SCHEDULE C -- PREMIUM
Premium $ ~/AZVED
The following exclusion is added to Paragraph 2., Exclusions
of Section I -- Coverage A -- Bodily Injury And Property
Damage Liability and paragraph 2., Exclusions of Section I
-- Coverage B -- Personal And Advertising Injury Liability:
2. Exclusions
This insurance does not apply to "bodily injury",
"property damage" or "personal injury" and "advertis-
ing injury" (or "personal and advertising injury" if
defined as such in your policy) arising directly or
indirectly out of=
a. Any actual or alleged failure, malfunction or inad-
equacy of:
(1) Any of the following, whether belonging to
any insured or to others=
(a) Computer hardware, including
microprocessors~
(b) Computer application softwara;
(c) Computer operating systems and related
software;
(d) Computer networks;
(e) Microprocessors (computer chips) not
part of any computer system; or
(f) Any other computerized or electronic
equipment or components; or
(2) Any other products, and any services, data
or functions that directly or indirectly use or
rely upon, in any manner, any of the items
listed in Paragraph 2.a.(1) of this endorse-
ment
due to the inability to correctly recognize,
process, distinguish, interpret or accept the year
2000 and beyond.
b. Any advice, consultation, design, evaluation,
inspection, installation, maintenance, repair, re-
placement or supervision provided or done by you
or for you to determine, rectify or test for, any
potential or actual problems described in Para-
graph 2.a. of this endorsement.
This exclusion does not apply to the types of injury or
damage indicated in Schedule A-- Coverages To Be
Provided of this endorsement a rising out of a ny opera-
tions, products or services, or any operations or ser-
vices at or from any specific location, described in
Schedule B -- Description Of Location, Operations,
Products Or Services To Be Covered of this endorse-
ment.
POLICY NUMBER: 0PR665585 SERV]'CE OFFZCE COPY
CGL
CG2026 11 85
CL, 261
(! 1-85)
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: NICHOLS, ~/H H. & OEO
(If no entry appears above, information required to complete this endorsemen~ will be shown in the Declarations as applicable
to this endorsement,)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as
an insured but only with respect to liability arising out of your operations or premises owned by or rented to you.
POLICY NUMBER: QPR665385 SERV:LCE OFF]'CE COPY
CG 20 26 11 85 (11-85)
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART
SOHEDULE
Name of Person or Organization: NICHOLS S NICHOLS PA
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable
to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as
an insured but only with respect to liability arising out of your operations or premises owned by or rented to you.
POLICY NUMBER: gPR665585 SERVICE OFFICE COPY
PRODUCTS/COMPLETED OPERATIONS HAZARD REDEFINED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
Description of Premises and Operations:
].6815 RESTAURANT
CL826
(1-96)
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
With respect to "bodily injury" or "property damage" arising
out of "your products" manufactured, sold, handled or dis-
tributed:
1. On, from or in connection with the use of any premises
described in the Schedule, or
2. In connection with the conduct of any ope[ation described
in the Schedule, when conducted by you or on your behalf.
Paragraph a. of the definition of "Products-completed opera-
tions hazard" in the DEFINITIONS Section is replaced by the
following:
"Products-completed operations hazard":
a. Includes all "bodily injury" and "property damage" that
arises out of "your products" if the "bodily injury" or
"property damage" occurs after you have relinquished
possession of those products.
POUCYNUUBER: QPR665~85 SERVi'CE OFF1'CE COPY
CGLJ
G10817 0796
HIRED AUTO AND NON-OWNED AUTO LIABILITY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Liability
SCHEDULE
Insurance is provided only with respect to those coverages for which a specific premium charge is shown:
HIRED AUTO LIABILITY
State Estimated Cost of Hire Rates per $100 Advance ~'~}lum
PA IF ANY VAR]~ES e97
J Sub Total t97
NON-OWNED AUTO LIABILITY
Number of Employees Advance Pre,~ium
I t151
Sub Total t151
Total Advance Premium ~228
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
HIRED AUTO LIABILITY
The insurance provided under COVERAGE A (Section I)
applies to "bodily injury" or "property damage" arising out
of the maintenance or use of a "hired auto" by you or your
employees in the course of your business.
NON-OWNED AUTO LIABILITY
The insurance provided under COVERAGE A (Section I)
applies to "bodily injury" or "property damage" arising out
of the use of any "non-owned auto" in your business by
any person other than you.
FOR THE PURPOSES OF THESE COVERAGES ONLY
1. Exclusions c, e, g, h, j, k, 1, m and n, under COVER-
AGE A (Section I) are deleted.
2. The following exclusions are added:
There is no coverage for..
a. "Bodily Injury" or "property damage" for which
the insu red is obligated to pay da mages by reason
of the assumption of liability in a contract or
agreement. This exclusion does not apply to
liability for damages:
(1) That the insured would have in the absence
of the contract or agreement; or
(2) Assumed in a contract or agreement that is
an "insured contracf', provided the "bodily
Injury" or "property damage" occurs sub-
sequent to the execution of the contract or
agreement.
b. "Bodily Injury" to
(1) an employee of the insured arising out of or
in the course of employment by the insured;
or
(2) the spouse, child, parent, brother or sister of
that employee as a consequence of (1)
above.
This exclusion applies:
(1) Whether the insured may be liable as an
employer or in any other "capacity"; and
(2) To any obligation to share damages with or
repay someone else who must pay damages
because of injury.
This exclusion does not apply to:
(1) Liability assumed by the insured under an
"insured contract"; or
(2) "Bodily Injury" arising out of and in the
course of domestic employment by the in-
sured unless benefits for such injury are in
whole or in part either payable or required to
be provided under any workers compensa-
tion law.
c. "Property Damage" to:
(1) property owned or being transported by, or
rented or loaned to the insured; or
POLICY NUMBER: QPR665585 SERVZCE OFFZCE COPY
CGU
(2) property in the care, custodyorcontrolofthe
insured,
3. WHO IS AN INSURED (Section II) is replaced by the
following:
Each of the following is an insured under this in-
surance to the extent set forth below:
a. You;
b. Any other person using a "hired auto" with your
permi~siom
c. With respect to a "non-owned auto", any partner
or executive officer of yours, but only while such
"non.owned auto" is being used in your business;
d. Any other person or organization, but only with
respect to their liability because of acts or omis-
sions of an insured under a., b., or c. above.
None of the following is an insured:
a. Any person engaged in the business of his or her
employer with respect to "bodily injury" to any
co-employee of such person injured in the course
of employment;
b. Any partner or executive officer with respect to
any "auto" owned by such partner or officer or a
merober of his or her household:
c. Any p~rson while eroployed in or otherwise
engaged in duties in connection with an "auto
business" other than an "auto business" you
operate;
d. The owner or lessee (of whoro you are a sub-
lessee) of a "hired auto" or the owner of a
Form Nm G108171
07 96~
"non-owned auto" or any agent or employee of
any such owner or lessee;
e. Any parson or organization with respect to the
conduct of any current or past partnership or joint
venture, or limited liability company, that is not
shown as a Named Insured in the Declarations.
4. The General Aggregate Limit for Coverage A (Section
111.2.b.) does not apply, but the Each Occurrence
Limit does apply.
5. The Excess Insurance Condition (Section IV.4.b.3.) is
replaced by the following:
(3) If the loss arises out of the maintenance or use
of aircraft, "autos" or watercraft to the extent:
(a) not subject to Exclusion g. of Coverage A
(Section I); or
(b) covered under the Hired Auto and Non-
Owned Auto Liability coverage.
6. The following additional definitions apply:
"Auto business" means the business or occupation of
selling, repairing, servicing, storing or parking "autos".
"Hired auto" means any "auto" you lease, hire, or
borrow. This does not include any "auto" you lease,
hire, or borrow from any of your employees or mero-
bers of their households, or from any partner or
executive officer of yours.
"Non-owned auto" means any "auto" you do not own,
lease, hire or borrow which is used in connection with
your business. However, if you are a partnership, a
"non-owned auto" does not include any auto owned
by any partner,
POUCYNUMBER: {;1PR665585 SERVICE OFFICE COPY
CGU
CG2011 O1 96
ADDITIONAL INSURED--MANAGERS OR LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
1. Designation of Premises (Part Leased to You): 114 BRTDGE STREET
2. Name of Person or Organization (Additional Insured): E OF JUL[E OASPER
3. Additional Premium; INCLUDED
CLaOa
(1-96)
(If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable
to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as
an insured the person or organization 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;
This insurance does not apply to:
1. Any "occurrence" which takes place after you cease to be
a tenant in that premises.
2. Structural alterations, new construction or demolition
operations performed by or on behalf of the person or
organization shown in the Schedule.
POLICY NUMBER: QPR665585 SERVZCE OFF[CE COPY
CGLI
COMMERCIAL ACCOUNT POLICY
COMMERCIAL CRIME
COVERAGE PART DECLARATIONS
GENERAL ACCIDENT IN. ZANCE CO. OF AMERICA
A Stock Company, Boston, M,~ssachusetts 02108-3100
I QF'R665565 05/01/2001
N,4MED INSURED
HICK'S 11~ CAFE
SEE ATTACHED SCHEDULE FOR LIMITS OF INSURANCE AND DEDUCTIBLES.
PLAN: 01 COHS SEPARATE LZHZTS
COVERAGE FORM & DESCRIPTION BY PERSON / POSITION UMIT DEDUCTIBLE
00001 001 C-1-PREHS-THEFT,D & D 20,000 50
00001 001 C-Z-HSNSRoTHEFT,D & D I ZO,O00 50
By acceptance of this policy you give us notice cancelling prior policy or bond No(s).
The cancellation to be effective at the time this policy Is effective.
G66976 (Ed. 6-94) Page 01 of 0z
SERVTCE OFFICE COPY
U
COMMERCIAL ACCOUNT POLICY
SUMMARY OF
CHANGE
I' QpR665585 I0/09/200! I
N4ME§ INSURED
NZCKtS 114 CAFE
NAHED INSURED AND NAILING ADDRESS
NICK'S 114 CAFE
114 BRIDGE STREET INC. T/A
114 BRIDGE STREET
NEW CUHBERLAND PA 17070-21Z3
AGENCY NAHE AND ADDRESS
NEW CUHBERLAND AGENCY, ZNC
516 BRIDGE STREET, PO BOX 310
NEW CUHBERLAND PA 17070
POLICY CHANGE NUHBER: 001 POLICY CHAN6ES EFFECTIVE: 07/01/2001
AS A RESULT OF THE CHANGE(S) HADE ON THE POLICY CHANGES EFFECTIVE DATE:
1. THIS POLICY. CHANGES ENDORSEHENT (INCLUDING THE REVISED DECLARATIONS
PAGES AND SCHEDULES PLUS ANY REVISED, OR ADDITIONAL FORHS OR
ENDORSEHENTS) UPDATES THE POLICY TO SHOW COVERAGES AS OF THE POLICY
CHANGES EFFECTIVE DATE;
2. ANY FORH WHICH HAS BEEN REHOVED FROH A LOCATION SCHEDULE NO LONGER
APPLIES TO THAT LOCATION;
3. ANY OTHER FORH OR ENDORSEHENT CONTINUES TO APPLY WITH NO CHANGES.
THE REVISED PREHIUNS FOR THIS POLICY PERIOD ARE SHOWN IN THE ATT"~CHED PAGES;
THE CHANGE ZN PREHIUH FOR THE REHAINDER OF THE
POLICY PERIOD IS AN ADDITIONAL PREHIUH OF= $1.00WAIVED
IT IS AGREED LOCATION 3-1, 1-15 N. THIRD STREET, NEW CUHBERLAND, PA
17070, IS ADDED FOR GENERAL LIABILITY COVERAOE ONLY CLASS 46&04 -
PARKING LOT - ~600 SALES BASIS.
G65982 (Ed. 8.94)
POMCY NUMKR~ (IPR6&5585
OFFICE~ C~U HARRTSBURO
SERVICE OFFICE COPY
Page ol of
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
IMMEBmSUREBandMAlUtlEADORESS~
NICK'S 114 CAFE
'114 BRIDGE STREET INC. T/A
114 BRID6E STREET
NEW CUHBERLAND, PA 17070-2125
br'l'Nl:l~/~l, fl~l..I..IUf'l~l I I1~. K/~I~II,.I: I.U. UJ'
A Stock Company, Boston, Massachusetts 02108-3100
QPR665585 lO/09/ZO01 I
TJMNS~CTIO~ ENDORSEHENT
REXNUMBER: ODSETX
EFFECIIVEDA~ 07/01/2001
BUS/NESS: RESTAURANT/BAR
FORM OF BUSINF. SS: CORPORATION
POUCt'PEIgOO: From 05/29/2001 to 05/29/2002 at 12:01 A.M. Standard Timeatyour mailing address.
In return for the payment of the premium, and subject to all terms of this policy, we agree with you to provide the insurance stated in this policy.
COFERAE;E PARTS and SUPPLEMENT'~ PRE. MI#M*
CONNERCIAL PROPERTY COVERA6E PART
CONNERCIAL GENERAL LIABILITY COVERA6E PART
LIQUOR LIABILITY COVERAGE PART
CONNERCIAL CRINE COVERA6E PART
$4,560.00
$10,077.00
$22,885.00
$157.00
TOTAL ~$7,779.00
PRENIUH SHOWN IS PAYABLE ON INSTALLNATIC NONTHLY PLAN
* This premium may be subject to adjustment.
The above numbered policy is completed by the use of these common declarations and the applicable coverage part declarations,
together with the common policy conditions, coverage form(s) and forms and endorsements, if any.
NAME amlAPD.'~,SS OFAOFNT: COUNTE~
(Authorized Representative)
(Data)
G669~6 (Ed, 6-94)
o~lqcE, COU HARRISBURG
SERVICE OFFZCE COPY
Page el of 05
~ZO7 ~* 8~.137so
CGU
GENERAL ACCIDENT INS' ~RNCE CO. OF AMERIC-A
A Stock Company, Boston, Massachusetts 0~108-3100
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
QPR66S$S5 J 10/09/7001
ag4MF.~/~S//~'~
NICK'S 11q CAFE
PREM~ES BUlLiNG ......
NO. I NO. I tJ4a~UPAI~R,;, I ADORE,
00001 001 RESTAURANT 114 BRZDOE STREET
- NEW CUMBERLAND, PA 17070-Z125
00002 001 THREE FAMZLY DWELLZN 122-124 BRZDeE STREET
NEW CUMBERLAND, PA 17070
00005 001 PARKIN8 LOT 1015 N. THIRD STREET
NEW CUMBERLAND, PA 17070
G669~8(Ed. 6-94) SERVZCE OFFZCE COPY Page e2 of es
OFFICE: C~U HARI~XSBUJ~ FILENUMBER~ HEX07 2 826*15700
COMMERCIAL ACCOUNT POLICY
COMMON POLICY
DECLARATIONS
~I:NI:RAL ACCIDENT I1~ iRANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02108-3100
NAMED INSURED
HICK'S 114 CAFE
The following is a listing of the declarsttons, forms, and endorsements which form your complete policy:
IRTERLZNE FORMS;
IL00171185
ZL09100161
G107790588
1L0172119S
ZL09550898
$1509Z0599
ZLOZ460500
ZL01660199
ZL02460498
ZLOO21049B
COMMON POLICY CONDITIONS
PENNSYLVANIA NOTICE
EXECUTION OF OFFICERS~ SIGNATURES
PA.CHANGES
EXCL.OF CENT.COMP.RELATED LOSSES
POLICY HOLDER NOTICE
PA. CHANGES - CANC. AND NOHRENEWAL
PENN. CHNGS.- ACTUAL CASH VALUE
PENNSYLVANIA CHGS-CANCL B NON-RENEWAL
NUCLEAR ENERGY LZAB EXCL (BROAD FORM)
PROPERTY FORM COVERAGES;
CP00900788 COMMERCIAL PROPERTY CONDITIONS
CP01860486 CHANGES-POLLUTANTS
CP00100695 BUILDING AND PERSONAL PROPERTY
CP10500695 CAUSES OF LOSS-SPECIAL FORM
6155240300 CGU CP COY AMENDMENTS EXT ENDT
G155ZSOSO0 CGU CP SEC FOR PROPERTY EXT ENDT
CPOO$OO&95 BUSINESS INCOME &EE OTHER
CP155&OZ97 BI-PERIOD OF REST - NO WAIT
LIABILITY FORM COVERAGES;
LZ951019S
CGZ4070196
6108170796
G141530996
LZBZB0993
CG04310998
CG20110196
CGZOZ61165
CG21470798
6155530500
6155430500
CG00010798
CG00331093
CRIME FORH COVERAGESI
CR00041090
CR10000497
EXCLUSZOH-LEAD LIABILITY-PA
PROD/COHP OPERATIONS HAZARD REDEFINED
HIRED & NON-OWNED AUTO LIAB.
POLICYHOLDER NOTZFICATZON-CG2147
EXCLUSION - ASBESTOS LIABILITY
YR 2000 COMPUTER RELATED LTD. COVG.
MANAGERS OR LESSORS OF PREMISES
DESZGHATED/PERSON ORGANIZATION(CLASS)
EHPLOYMEHT RELATED PRACTICES EXCLUSION
POLICYHOLDER NOTICE
BRIDGE ENDORSEMENT
COHMERCZAL GENERAL LIABILITY COVGE FORM
LIQUOR LIABILITY COVERAGE FORM
THEFT DISAPPEARANCE & DESTRUCTION
CRIME GENERAL PROVISIONS - LOSS SUS
ZSO COPYRIGHT, INSURANCE SERVICES OFFICE, INC., 1983, 1984, 1985, 1986, 1987,
1988, 1989, 1990, 1991, 199Z, 199S, 1994.
COPYRIGHT, COMMERCIAL UNION INSURANCE COMPAHY, !992
Page 03 of 03
G66978(Ed. 6.94) SERVICE OFFICE COPY
OFFiCg, COU HARRISBURG FILENUMI~ER~ I4EZ07 2 82gklS?Oa
COMMERCIAL ACCOUNT POLICY
COMMERCIAL PROPERTY
COVERAGE PART DECLARATIONS
GENERAL ACCIDENT I~ ,RANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 02108-3100
NAMED INSURED
NICK'S 114 CAFE
COVERAGE (S)
BUZLDIH6
LIMIT OF INSURANCE:
DEDUCTIBLE~
COINSURANCE:
OPTIONAL COVERAGES:
REPLACEMENT COST~
COV AMEND ENDT;
SEC FOR PROP ENDT~
COVERED CAUSE OF LOSS~
BASIC GROUP I
BASIC GROUP II
SPECIAL
PENS PROP-INSD
LIMIT OF INSURANCE:
DEDUCTIBLE~
COINSURANCE~
OPTIONAL COVERAGES~
REPLACEMENT COST~
COVERED CAUSE OF LOSS~
BASIC GROUP I
BASIC GROUP II
SPECIAL
SPECIAL THEFT OTH ZHCREM
BI&EE OTHER
LIMIT OF INSURANCE~
DEDUCTIBLE~
COINSURANCE;
OPTIONAL COVERA6ES~
COVERED CAUSE OF LOSS~
BASIC GROUP Z
BASIC GROUP IZ
SPECIAL
BI&EE RENTAL
LIMIT OF INSURANCE~
DEDUCTIBLE~
COINSURANCE:
OPTIONAL COVERAGES~
COVERED CAUSE OF LOSS~
BASIC OROUP I
BASIC 6ROUP II
SPECIAL
PREMISEB NO. BUILDING NO.
00001 001
SPECIAL
$401,700
91,000
90~
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
SPECIAL
$65,200
~l,O00
90~
APPLIES
APPLIES
APPLIES
APPLIES
APPLIES
SPECIAL
elOO,O00
80~
NONE
APPLIES
APPLIES
APPLIES
DOES HOT APPLY
PREMISES NO. BUILmNGNO.
00002 001
SPECIAL
~115,$00
$1,000
90~
APPLIES
APPLIES
DOES NOT APPLY
APPLIES
APPLIES
APPLIES
DOES NOT APPLY
DOES HOT APPLY
.SPECIAL
~12,000
100~
NONE
APPLIES
APPLIES
APPLIES
G669~9 (Ed. 6-94) Page 01 of
SERVICE OFFICE COPY
o~*~cg~ cGu HARRISBURG FILENUMOE~ NE/07
COMMERCIAL ACCOUNT POLICY
COMMERCIAL GENERAL LIABILITY
COVERAGE PART DECLARATIONS
L~I:I'di:K/%L ~t.~ILJI:I~I I I[~ )K,~I~.I: ~..u. Ur AMI:Kli-A
A Stock Company, Boston, Massachusetts 02108-3100
NAMED INSURED
NICK'S ].14 CAFE
General Aggregate Limit (Other then Products--Completed Operations)
Products--Completed Operations Aggregate Umit
Personal and Aclve~tising Injury Umit
Each Occurrence Limit
Fire Damage (any one fire) Umtt
Medical Expenses (any one person) Limit
$1,000,000
~500,000
$500,000
~500,000
~100,000
~5,000
ALLCLASSIFICATIONSAPPLICABLETOTHISCOVERAGEFORM MAY BEFOUNDIN THE ATTACHED SCHEDULES.
PRODUCTS AND COMPLETED OPERATIONS $1,203.00
ALL OTHER ~8,87q.00
TOTAL e]*0,077.00
60001 001 RSTRNTS-#ZTH SALES OF ALCH BEV THAT AR 1681S PREH'rSES PER 01000 SALES 1,,386,000 &.1159 08,e,77
00001 001
8ooal ool
ooool 0Ol
00001 OOl
00001 OOl
00001 OOl
00001 OOl
00002 ool
LESS THAN TaX OF THE TOTAL ANN RECEIPT
OF THE RESTAURANT$-#ZTH DANCE FLOOR
RSTRNTS-#ZTH SALES OF ALCH BEV THAT AR 16~15 PRODUCTS
LESS THAN 75X OF THE TOTAL ANN RECEIPT
OF THE RESTAURANTS-#ETH DANCE FLOOR
EHPLOYERS NON-OHNERSHZP AUTO LZAB 66010 SPECIAL
0-2.6 EHPLOYEES
HIRED AUTO LZABZLZTY COVERASE 66190 SPECIAL
#ANAGERS OR LESSORS OF PREHZSES 49950 PREMISES
DESIGNATED/PERSON ORGANIZATiON(CLASS) 4995a PREHZSES
DESIGNATED PERSON/ORSAN~ZATZOO(LOCATEO 49950 PREHZSES
DESIGN&TED PERSON/OROANZZAT/ON(LOCATZO 499S0 pRODUCTS
DffELLINOS- THREE-FAtJZLY (LE$SOR'S RZSK &sa12 PREHZSES
ONLYJ-ZNCL PROD/COHPL OPS
PER 01000 SALES 1,386,000 0.8676 01,203
N~R OF EMPLOYEES I t101
140 EXPOSURE I 097
D~ELLZHG$ I 117.6~ $118
* Th~s premium may be sub~ect to adjustment.
G~6970 (Ed. 6-9,4)
of Fic~ (:GU HARSZSBURG
SERVICE OFFICE COPY
Page 01 of 02
FILENUIdBERz NET07 2 82413700
CGU
GENERAL ACCIDENT lNg ~ANCE CO. OF AMERICA
A Stock Company, Boston, Massachusetts 0210&3100
COMMERCIAL ACCOUNT POLICY
COMMERCIAL GENERAL LIABILITY
COVERAGE PART DECLARATIONS
NICK'S 114 CAFE
DEGCRIPTION OF CLASSIFICATION CODE SUBLINE RATE B,A.ql8 AMOUNT FINAL RATE CHARGED
eJOO$ e01 PARKXNG-PUBL'rC-OPEN AXR- ~6611,~ PREHXSES PEll ~Xel~l SALES &Oe 3.5829
ZNCL PROD/CONPL OPS
G6697! (Ed. 6-94) Page e2 of e2
SERVZCE OFFZCE COPY
OFFIC~ C~U ~.~2ZS~UR~ FILENUMBE~ HEZ67 2 8~i.1578e
COMMERCIAL ACCOUNT POLICY
COMMERCIAL' LIQUOR LIABILITY
COVERAGE PART DECLARATIONS
GENERAL ACCIDENT INr 'RANCE CO. OF AMERICA
A Stock Company, Boston, MassachuseLL~ 02108-3100
NAMED INSURED
NICK'S, 11c~ CAFE
Aggregate Limit 4~1, OOO, 000
Each Common Cause Umit $500,000
ALL CLASSIFICATIONS APPLICABLE TO THIS COVERAGE FORM MAY BE FOUND IN THE ATTACHED SCHEDULES.
ATTACHED SCHEDULE(S) eZZ,885. O0
TOTAL SZZ, 885.00
PREM BLDG CLASS EXPOSURE ANNUAL PREMIUM
NO. NO. DESCRIPTION OF CLASSIFICATION COOE RATE BASIS AMOUNT FINAL RATE CHARGED
80001 001 RESTAURANTS~ TAVERNS, HOTELS, NSTELS - 58161 PER 4~1000 SALES 911;3.00 2~.1150 1~22,8~6
ZNCLUDZNS PACKAGE SALES
* This premium may be subject to adjustment.
G66972 (Ed. 6.94)
OFF,C[: CGU HARRZSBURG
SERVZCE OFFZCE COPY
Page e! of Ol
FILENUMBER~ NEZO7 2 8L~kI$700
'CGU
CG043'[ 09 98
' YEAR 2000 COMPUTER-RELATED AND OTHER ELECTRONIC PROBLEMS
LIMITED COVERAGE OPTIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
.SCHEDULES
SCHEDULE A ~ COVERAGES TO BE PROVIDED (SUBJECT TO THE DESCRIPTION IN SCHEDULE B)
Check any one or more of the following:
[] Bodily Injury [] Property Damage [] Personal and Advertising Injury
SCHEDULE B -- DESCRIPTION OF LOCATION, OPERATIONS, PRODUCTS OR SERVICES TO BE COVERED
(TO WHICH SCHEDULE A APPLIES)
Description of location(s) operation(s), product(s) or service(s)
All locations, operations, products or sewices to which this policy applies.
SCHEDULE C -- PREMIUM
Premium $ WATVED
The following exclusion is added to Paragraph 2., Exclusions
of Section I -- Coverage A -- Bodily Injury And Prope~y
Damage Liability and Paragraph 2. Exclusions of Section I
-- Coverage B -- Personal And Advertising Injury Liability:
2. Exclusions
This insurance does not apply to "bodily injury",
"property damage" or "personal injury" and "advertis-
ing injury" (or "personal and advertising injury" if
defined as such in your policy) arising directly or
indirectly out of:
a. Any actual or alleged failure, malfunction or inad-
equacy of:
(1) Any of the following, whether belonging to
any insured or to others:
(a) Computer hardware, including
microprocessors;
(b) Computer application software;
(c) Computer operating systems and ralated
software=
(d) Computer networks;
(e) Microprocessors (computer chips) not
part of any computer system; or
(f) Any other computerized or electronic
equipment or components; or
(2) Any other products, and any services, data
or functions that directly or indirectly use or
rely upon, in any manner, any of the items
listed in Paragraph 2.a.(1) of this endorse-
ment
due to the inability to correctly recognize,
process, distinguish, interpret or accept the year
2000 and beyond.
b. Any advice, consultation, design, evaluation,
inspection, installation, maintenance, repair, re-
placement or supervision provided or done by you
or for you to determine, rectify or test for, any
potential or actual problems described in Pare-
graph 2.a. of this endorsement.
This exclusion does not apply to the types of injury or
damage indicated in Schedule A -- Coverages To Be
Provided of this endorsement a rising out of any opera-
tions, products or services, or any operations or ser-
vices at or from any specific location, described in
Schedule B -- Description Of Location, Operations,
Products Or Services To Be Covered of this endorse-
ment.
POLICY NUMBER: QPR665585 SERVZCE OFFZCE COPY
CGU
CG2026 !185
CL 261
(1 [-85)
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: NZCHOLS, WH H. & 8EO
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable
to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as
an insured but only with respect to liability arising out of your,operations or premises owned by or rented to you.
POUCYNUMaER: QPR665585 SERVTCE OFFZCE COPY
CGL!
CG2026 1185
CL 261
(11-85)
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: NTCHOLS & NTCHOLS PA
(If no entry appears abOve, information required to complete this endorsement will be shown in the Declarations as applicable
to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as
an insured but only with respect to liability arising out of your operations or premises owned by or rented to you.
POLICY NUMBER: 0PR665585 SERVZCE OFFXCE COPY
'CGL!
CG2407 01 96
PRODUCTS/COMPLETED OPERATIONS HAZARD REDEFINED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
Description of Premises and Operations:
168].5 RESTAURANT
CL826
(1-96)
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
With respect to "bodily injury" or "property damage" arising
out of "your products" manufactured, sold, handled or dis*
tributed:
1. On, from or in connection with the use of any premises
described in the Schedule, or
2. In connection with the conddct of any operation described
in the Schedule, when conducted by you or on your behalf.
Paragraph a. of the definition of "Products-completed opera-
tions hazard" in the DEFINITIONS Section is replaced by the
following:
,preducts-completed operations hazard":
a. includes all "bodily injury" and "property damage" that
arises out of "your products" if the "bodily injury" or
"property damage" occurs after you have relinquished
possession of those products.
POLICY NUMBER: QPR665585 SERVTCE OFFTCE COPY
CGU '
Gl0817 07 96
HIRED AUTO AND NON-OWNED AUTO LIABILITY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Liability
SCHEDULE
Insurance is provided only with respect to those coverages for which a specific premium charge is shown:
HIRED AUTO LIABILITY
State Estimated ,Cost of Hire Rates per $100 Advance Premium
PA TF ANY VARI'ES ~97
I Sub Total e97
NON-OWNED AUTO LIABILITY
Number of Employees Advance
! t151
l Sub Total ~131
Total Advance Premium eZg8
(if no entry appears above, information required to complete this endorsement wilt be shown in the Declarations as applicable to
this endorsement.) '
A. HIRED AUTO LIABILITY
The insurance provided under COVERAGE A (Section I)
applies to "bodily injury" or "property damage" arising out
of the maintenance or use of a "hired auto" by you or your
employees in the course of your business.
B. NON-OWNED AUTO LIABILITY
The insurance provided under COVERAGE A (Section I)
applies to "bodily injury" or "property damage" arising out
of the use of any "non-owned auto" in your business by
any person other than you.
C. FOR THE PURPOSES OF THESE COVERAGES ONLY
I. Exclusions c, e, g, h, j, k, 1, m and n, under COVER-
AGE A (Section I) are deleted.
2. The following exclusions are added:
"Bodily Injury" to
(1) an employee of the insured arising out of or
in the course of employment by the insured;
or
(2) the spouse, child, parent, brother orsister of
that employee as a consequence of (1)
above.
This exclusion applies:
(1) Whether the insured may be liable as an
employer or in any other "capacity"; and
(2) To any obligation to share damages with or
repay someone else who must pay damages
because of injury.
This exclusion does not apply to;
There is no coverage for: (1) Liability assumed by the insured under an
a; "Bodily Injury"TOt"property damage· fo~which "insured contract"; or
the insured is obligated to pay damages by reason (2) "Bodily Injury" arising out of and in the
of the assumption of liability in a contract or course of domestic employment by the in-
agreement. This exclusion does not apply to
liability for damages:
(1) That the insured would have in the absence
of the contract or agreement; or
(2) Assumed in a contract or agreement that is
an "insured contract~', provided the "bodily
Injury" or "property damage" occurs sub-
sequent to the execution of the contract or
agreement.
sured unless benefits for such injury are in
whole or in part either payable or required to
be provided under any workers compensa-
tion law.
"Property Damage~' to=
(1) property owned or being transported by, or
rented or loaned to the insured; or
POUCYNUMBER: ~PR665585 SERV]'CE OFFTCE COPY
'CGL!
(2) property in the care, custody or control of the
insured.
WHO IS AN INSURED (Section II)' is replaced by the
following:
Each of the following is an insured under this in-
surance to the extent set forth below~
a, You;
b. Any other person using a "hired auto" with your
permission;
c. With respect to a "non-owned auto", any partner
or executive officer of yours, but only while such
"non-owned auto" is being used in your business:
d. Any other person or organization, but only with
respect to their liability because of acts or omis-
sions of an insured under a., b., or c. above.
None of the following is an insured:
a. Any person engaged in the business of his or her
employer with respect to "bodily injury" to any
co-employee of such person injured in the course
of employment;
b. Any partner or executive officer with respect to
any "auto" owned by such partner or officer or a
member of his or her household;
c. Any person while employed in or otherwise
engaged in duties in connection with an "auto
business" other than an "auto business" you
operate;
d. The owner or lessee (of whom you are a sub-
lessee) of a "hired auto" or the owner of a
Form Nm G10817'
07 96
Page 2 of 2
"non-owned auto" or any agent or employee of
any such owner or lessee;
e. Any person or organization with respect to the
conduct of any current or past partnership or joint
venture, or limited liability company, that is not
shown as a Named Insured in the Declarations.
4. The General Aggregate Limit for Coverage A (Section
111.2.b.) does not apply, but the Each Occurrence
Limit does apply.
5. The Excess Insurance Condition (Section IV.4.b.3.).is
replaced by the following:
(3) If the loss arises out of the maintenance or use
of aircraft, "autos" or watercraft to the extent:
(a) not subject to Exclusion g, of Coverage A
(Section I); or
(b) covered under the Hired Auto and Non-
Owned Auto Liability coverage.
6. The following additional definitions apply:
"Auto business" means the business or occupation of
selling, repairing, servicing, storing or parking "autos".
"Hired auto" means any "auto" you lease, hire, or
borrow. This does not include any "auto" you lease,
hire, or borrow from any of your employees or mem-
bers of their households, or from any partner or
executive officer of yours,
"Non-owned auto" means any "auto" you do not own,
lease, hire or borrow which is used in connection with
your business. However, if you are a partnership, a
"non-owned auto" does not include any auto owned
by any partner.
pou~ NUMBER: QPR665385 SERVICE OFFICE COPY
CGU '
CG2011 0196
c~8oa
(1-96)
ADDITIONAL INSURED--MANAGERS OR LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
1. Designation of Premises (Part Leased to You): 114 9RZDeE STREET
2, Name of Person or Organization (Additional insured): E OF JULZE CASPER
3. Additional Premium: ZNCLUDED
(If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable
tO this endorsement.)
WHO IS AN INSURED (section II) is amended to include as
an insured the person or organization shown in the Schedule
but only with respect to liability arising out of the ownership,
maintenance or use of that pert of the premises leased to you
and shown in the Schedule and subject to the following
additional exclusions:
This insurance does not apply to:
1. Any "occurrence" which takes place after you cease to be
a tenant in that premises,
2, Structural alterations, new construction or demolition
operations performed by or on behalf of the person or
organization shown in the Schedule,
POLICYNUMBERt QPR665585 SERVI'CE OFFZCE COPY
CGU
GENERAL ACCIDENT IN RANCE CO. OF AMI:RIt~^
A Stock Company, Boston, Massachusett~ 02108-3100
COMMERCIAL ACCOUNT POLICY
COMMERCIAL CRIME
COVERAGE PART DECLARATIONS
?lAMED INSURED
NZCK~S 114 CAFE
SEE ATTACHED SCHEDULE FOR LIMITS OF INSURANCE AND DEDUCTIBLES.
PLAN~ 01 COMB SEPARATE LIMITS
COVERAGE FORM & DESCRIPTION
BY PERSON I POSITION
LIMIT DEOUCTIBLE
PREM COVERAGEFORM&DESCRIPTION NUMBEROFM~S~GERS LIMIT DEDUCTIBLE
NO. ZO,OOO 50
00001 001 C-1-PREMS-THEFT,D a D 50
00001 001 C-Z-MSN6R-THEFT,D & D I 20,000
The cancellation to be effectNe at the time this policy is effective.
666976 (Ed. 6-94)
OFFICE: CGU HAItRXSBUR8
SERVICE OFFICE COPY
Page 01 of 01
FILENUMB~ HEZ07 2 82q13700
,REMIUM AUDIT INVOICE
PAGE NO.
REX NO.
AUDtT DATE
NZCK~ 114 CRFE
1t4 BRTDEIE ~I*REET TNC. T/R
114 BRZDOE i~TREET
NEGJ CUMBERL. RN~
NEt4 CUNE~ERLRND tNSURRNCE
P'O BOX 3:1,0
NEll CLMBERLRND
p,~ 17070-0~
581~1
17078
75
L ~S T
coMMERCIAL
INSURANCE CO. OF
ACCOUNT
A STOCK COMPANY
~M£RICA
pOl- [-C Y,
.!
· ,/,,FII~qL PREIfl[UM MIrY BE tqD,,I'LL~TED E,Y IM.ID'ET
CouNTE R~ I~.~,.~TURE D~¥~
COMPANY NFORMAllON
COMPANY COPY
GE~ kL AccIDENT INSURANCE COMPANY OF ~saN '~A
~ 100 CORPORATE CENTER DRIVE '-
P O BOX 8851
CAMPHILL PA 17001-8851
NOTICE OF NONRENEWAL OF INSURANCE
Nm'ned Insured x, Mailing Add. ss:
NICK'S 114 CAFE
114 BR.1I~E STREET INC T/A
114 BRIDGE STREET
NEW CUMBERLAND PA 17070-2123
produc~: 3796145
NEW CUMBERLAND AGENCY, RqC
516 BRIDGE STREET, PO BOX 310
NEW' C!d-b,~_ RRLAND PA 17070-0000
Policy No.: QPR665385
Type of Policy: PACKAGE
Date of Expiration: 03/29/2002; 12:01 A.M. Local Time at the mailing address of thc Named Insured.
We will not renew this policy when it ~xplres. Your insurmce will ceam on the Expiration Date shown
The reason for nonrenowal is POTEbFFIAL HAZARDS AND EXPOSURES ASSOCIATED WITH THIS
RISK, MATERIAL TO THE INSURABILITY, ARE UNACCEPTABLE.
You may request we pwvide you infomm~on about losses under this pohcy end previous policies, which
we have issued to you, not to exceed three ye~s. You must nmke your written requem within 10 days
from the receipt of this notice. We will provide the information to you within 30 days from the date
we receive your request.
This policy provides fir~ and extended cov~ insurance on your property. You should contact your
agent concerning coverage fluough another inanler, or your possible eligibility for coverage through
the Insurance Placement Facility (Fair Plan), 530 Walnut S~re~ Suite 1650, philadelphia, PA
19106-3698.
Named Insured
NICK'S 114 CAFE
114 BRIDGE STREET INC T/A
114 BRIDOE STREET
NEW CUMBERLAND PA 17070-2123
ODEN3.0.01.09a
FORM# CN96970104PA51995
Copy for Branch Office
Date Mailed:
18th day of January,2002
Authorizad C~npany Rep~san~tive
PACN 19NONE APP
01042002MYN
Page l of I
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONESEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a General Accident
Insurance Company of America
Plaintiff
VS.
1 14 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendant
: No. 03-3777 Civil
: CIVIL ACTION
CERTIFICATE OF SERVICE
The undersigned certifies that a true and correct copy of Plaintiff's Complaint was
served via first class mail, postage prepaid on August 13, 2003:
114 Bridge Street, Inc.
d/b/a Nick's 114 Cafe
114 Bridge Street
NEW CUMBERLAND PA 17070-2123
AM. ATO AND M~RGLE, P.~
Ronald Amato
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(610) 866-0400
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE
COMPANY f/k/a CGU INSURANCE
COMPANY d/b/a GENERAL
ACCIDENT INSURANCE COMPANY
OF AMERICA
Plaintiff
VS.
114 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendant
No. 03-3777 Civil
CIVIL ACTION
PRAECIPE TO SUBSTITUTE VERIFICATION
TO THE PROTHONOTARY OF CUMBERLAND COUNTY:
Kindly substitute of record the enclosed Verification of A~rlene M. Bleiler for Complaint,
in the above matter.
AMATO AND MARGLE, P.C.
By:
Attorney ID #32323
Attorneys for Plaimiff
107 North Commerce Way
Bethlehem PA 18017
(610) 866-0400
VERIFICATION
of OneBeacon insurance Co., Plaintiff in this action, and verifies that the statements made in
the attached Complaint are true and correct to the best of his/her knowledge, information and
belief. The undersigned understands that the statements herein are made subjeot to the
penalties of 18 PA C.S. §4904 relating to unsworn falsification to authorities.
NOT4RIAL ~
.cDE~ L. WI~, KES, ~Nl~d~y I~l~c
My ~ ExpOs 0~-t0~'~ 5, 2~6
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a GENERAL ACCIDENT
INSURANCE COMPANY OF AMERICA
Plaintiff
No. 03-3777 Civil
VS.
114 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendant
CIVIL ACTION
PRAECIPE FOR JUDGMENT
TO THE PROTHONOTARY, CUMBERLAND COUNTY:
Kindly enter judgment by default for want of an answer in favor of Plaintiff and against
the above-named defendant(s) only and assess damages as follows:
Debt
Interest (from August 8, 2003 to September 29, 2003
at 6% per annum)
Payments
$7,229.37
45.18
Total $7,274.55
I CERTIFY THAT THE FOREGOING ASSESSMENT OF DAMAGES IS FOR SPECIFIED
AMOUNTS ALLEGED TO BE DUE IN THE COMPLAINT AND IS CALCULABLE AS A SUM
CERTAIN FROM THE COMPLAINT.
Pursuant to RCP 237.1, I certify that a copy of the annexed written notice(s) of intention to
file this praecipe was mailed or delivered to all parties against whom judgment is to be entered
and to their attorney of record, if any, after the default occurred, and at least ten days prior
to the date of filing of this praecipe. Please note that said notice was mailed to all parties on
September 4, 2003.
Dated: September 29, 2003
2027151
AMATO AND MA~,~GLE, P.C.~,-~
Ronald Amato
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(610) 866-0400
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a GENERAL ACCIDENT
INSURANCE COMPANY OF AMERICA
Plaintiff
VS,
1 14 BRIDGE STREET, INC. d/b/a
NICK'S 1 14 CAFE
Defendant
No. 03-3777 Civil
CIVIL ACTION
CERTIFICATION OF ADDRESSES
I do certify that the precise last known address of the within named plaintiff is:
436 Walnut Street
Philadelphia PA 191063703
I do certify that the precise last known address of the within named defendant is:
114 Bridge Street
NEW CUMBERLAND PA 17070-2123
AMATO AND M~,GLE, P.~
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(610) 866-0400
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a GENERAL ACCIDENT
INSURANCE COMPANY OF AMERICA
Plaintiff No. 03-3777 Civil
VS.
.114 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendant
TO:
114 Bridge Street, Inc.
d/b/a Nick's 114 Cafe
114 Bridge Street
NEW CUMBERLAND PA 17070-2123
Date of Notice: September 4, 2003
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE
PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES
OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN
TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST
YOU WITHOUTA HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT
RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE
CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT
AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH
INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE
PERSONS AT A REDUCED FEE OR NO FEE.
Court Administrator
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013-3387
(717) 240-6200
Attorney File#2027151
AMATO AND
Ronald Amato
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(61 O) 866-0400
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ONEBEACON INSURANCE COMPANY
f/k/a CGU INSURANCE COMPANY
d/b/a GENERAL ACCIDENT
INSURANCE COMPANY OF AMERICA
Plaintiff
VS,
1 14 BRIDGE STREET, INC. d/b/a
NICK'S 114 CAFE
Defendant
No. 03-3777 Civil
CIVIL ACTION
NOTICE OF JUDGMENT
(XX)
()
NOTICE IS HEREBY GIVEN THAT A JUDGMENT IN THE ABOVE CAPTIONED
MATTER HAS BEEN ENTERED AGAINST THE ABOVE-NAMED DEFENDANT(s)
IN THE AMOUNT OF $7,274.55 ON , 2003.
A COPY OF ALL DOCUMENTS FILED WITH THE PROTHONOTARY OF
CUMBERLAND COUNTY IN SUPPORT OF THE WITHIN
JUDGMENT IS/ARE ENCLOSED.
PROTHONOTARY - CUMBERLAND COUNTY
If you have any questions concerning the above, please contact the undersigned.
AMATO AND MARGLE, P.C.
Ronald Amato
Attorney I.D. No. 32323
Attorneys for Plaintiff
107 North Commerce Way
Bethlehem, PA 18017
(610) 866-0400