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Home My WebLink About10-7421COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW ERIE INSURANCE EXCHANGE • \ Plaintiff No. CU _ ~ ~ al ~ .c l _~ ° rn r~--~ vs. r~i>r~" ~ r -nom -~C ~ ' HAMMER EXPRESS, INC. r - ~° 3 ~.~ CIVIL ACTION ~ ~ N ,~~ Defendant ~ ~ ~-+,, ~ 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 ATTORNEY 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, 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 AMATO AND LESSA, P.C. BY~ l ~ . ~ <~ ~Q ~~~ as ~y ~ma~ C~~ ~~a~131 ~~ psi Bd3 Ronald Amato, Esq., Atty ID #32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW ERIE INSURANCE EXCHANGE Plaintiff No. vs. HAMMER EXPRESS, INC. CIVIL ACTION Defendant COMPLAINT The above Plaintiff brings this action against the above Defendant to recover the sum of $17,030.38, with interest thereon as hereinafter stated, upon the following cause of action: 1. Plaintiff, ERIE INSURANCE EXCHANGE, is located at 100 Erie Insurance Place, Erie, PA 16530. 2. Defendant, HAMMER EXPRESS, INC., is located at 5845 Aspen Lane, Enola PA 17025. COUNTI Breach of Contract 3. At the request of Defendant, Plaintiff issued its Workers Compensation and Employers Liability policy of insurance, policy number Q89 1600553, naming Defendant as the insured, a true and correct copy of the information page and final audit statement for which are attached hereto, made a part hereof and collectively marked Exhibit "A." 4. Pursuant to the terms and conditions of said policy, Defendant was required to pay earned premiums based upon Defendant's actual payroll for the policy period. 5. However, the policy was issued to Defendant based upon an estimate of Defendant's payroll for the policy period and, therefore, the premiums due under the policy were also an estimate. 6. Subsequent to the termination of the policy, Plaintiff conducted an audit of Defendant's business records to determine Defendant's actual payroll for the policy period. 7. Based upon Defendant's actual payroll for the policy period, Defendant was required to pay more earned premiums than originally estimated. However, Defendant has failed to pay earned premiums in the amount of $10,147.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "B." 9. Defendant's failure to pay all earned premiums due Plaintiff for the extension of insurance coverage under the policy constitutes a breach of the policy. 10. Plaintiff has performed and complied with all terms and conditions required under said policy. 1 1. 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 November 29, 2010 the total amount of interest due to Plaintiff is $1,449.49. 12. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set forth above, from November 29, 2010 on down to the date of judgment in this matter. 13. Plaintiff has made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiff demands judgment against Defendant for $11,596.49 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff is entitled. COUNT II Alternative to Count I -Unjust Enrichment 14. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 15. At Defendant's request, Plaintiff conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 16. Defendant received and accepted the benefit of said services provided by Plaintiff. 17. At all times material hereto, Defendant was aware that Plaintiff was providing the aforesaid services to Defendant and that Plaintiff expected to be paid for such. 18. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiff to provide said services and to incur damages. 19. At all times material hereto, Defendant was unj ustly enriched by retaining the benefit of receiving said services without paying Plaintiff fair and reasonable compensation. 20. Allowing Defendant to retain the benefit of said services without paying fair compensation would be unjust. 21. 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 services described in the exhibits attached hereto in the amount of $10,147.00. WHEREFORE, Plaintiff demands judgment against Defendant for $10,147.00 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff may be entitled. COUNT III Breach of Contract 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. At the request of Defendant, Plaintiff issued its Ultraflex policy of insurance, policy number Q41 1650546, naming Defendant as the insured, a true and correct copy of the most recent renewal certificate for which is attached hereto, made a part hereof and marked Exhibit "C." 24. Pursuant to the terms and conditions of said policy, Defendant was required to pay earned premiums for the insurance coverage extended thereunder. 25. However, Defendant has failed to pay earned premiums in the amount of $2,296.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "D." 26. Defendant's failure to pay all earned premiums due Plaintiff for the extension of insurance coverage under the policy constitutes a breach of the policy. 27. Plaintiff has performed and complied with all terms and conditions required under said policy. 28. 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 November 29, 2010 the total amount of interest due to Plaintiff is $327.98. 29. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set forth above, from November 29, 2010 on down to the date of judgment in this matter. 30. Plaintiff has made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiff demands judgment against Defendant for $2,623.98 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff is entitled. COUNT IV Alternative to Count III -Unjust Enrichment 31. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 32. At Defendant's request, Plaintiff conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 33. Defendant received and accepted the benefit of said services provided by Plaintiff. 34. At all times material hereto, Defendant was aware that Plaintiff was providing the aforesaid services to Defendant and that Plaintiff expected to be paid for such. 35. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiff to provide said services and to incur damages. 36. At all times material hereto, Defendant was unjustly enriched by retaining the benefit of receiving said services without paying Plaintiff fair and reasonable compensation. 37. Allowing Defendant. to retain the benefit of said services without paying fair compensation would be unjust. 38. 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 services described in the exhibits attached hereto in the amount of $2,623.98. WHEREFORE, Plaintiff demands judgment against Defendant for $2,623.98 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff may be entitled. COUNT V Breach of Contract 39. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 40. At the request of Defendant, Plaintiff issued its Workers Compensation and Employers Liability policy of insurance, policy number Q92 5100132, naming Defendant as the insured, a true and correct copy of the information pages for which are attached hereto, made a part hereof and collectively marked Exhibit "E." 41. Pursuant to the terms and conditions of said policy, Defendant was required to pay earned premiums based upon Defendant's actual payroll for the policy period. 42. However, the policy was issued to Defendant based upon an estimate of Defendant's payroll for the policy period and, therefore, the premiums due under the policy were also an estimate. 43. Subsequent to the termination of the policy, Plaintiff conducted an audit of Defendant's business records to determine Defendant's actual payroll for the policy period. 44. Based upon Defendant's actual payroll for the policy period, Defendant was required to pay more earned premiums than originally estimated. 45. However, Defendant has failed to pay earned premiums in the amount of $1,290.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "F." 46. Defendant's failure to pay all earned premiums due Plaintiff for the extension of insurance coverage under the policy constitutes a breach of the policy. 47. Plaintiff has performed and complied with all terms and conditions required under said policy. 48. 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 November 29, 2010 the total amount of interest due to Plaintiff is $102.85. 49. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set forth above, from November 29, 2010 on down to the date of judgment in this matter. 50. Plaintiff has made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiff demands judgment against Defendant for $1,392.85 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff is entitled. COUNT VI Alternative to Count V -Unjust Enrichment 51. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 52. At Defendant's request, Plaintiff conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 53. Defendant received and accepted the benefit of said services provided by Plaintiff. 54. At all times material hereto, Defendant was aware that Plaintiff was providing the aforesaid services to Defendant and that Plaintiff expected to be paid for such. 55. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiff to provide said services and to incur damages. 56. At all times material hereto, Defendant was unjustly enriched by retaining the benefit of receiving said services without paying Plaintiff fair and reasonable compensation. 57. Allowing Defendant to retain the benefit of said services without paying fair compensation would be unjust. 58. 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 services described in the exhibits attached hereto in the amount of $1,290.00. WHEREFORE, Plaintiff demands judgment against Defendant for $1,290.00 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff may be entitled. COUNT VII Breach of Contract 59. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 60. At the request of Defendant, Plaintiff issued its Ultraflex policy of insurance, policy number Q44 0151498, naming Defendant as the insured, a true and correct copy of the most recent renewal certificate and declarations for which are attached hereto, made a part hereof and collectively marked Exhibit "G." 61. Pursuant to the terms and conditions of said policy, Defendant was required to pay earned premiums for the insurance coverage extended thereunder. 62. However, Defendant has failed to pay earned premiums in the amount of $731.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "H." 63. Defendant's failure to pay all earned premiums due Plaintiff for the extension of insurance coverage under the policy constitutes a breach of the policy. 64. Plaintiff has performed and complied with all terms and conditions required under said policy. 65. 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 November 29, 2010 the total amount of interest due to Plaintiff is $29.80. 66. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set forth above, from November 29, 2010 on down to the date of judgment in this matter. 67. Plaintiff has made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiff demands judgment against Defendant for $760.80 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff is entitled. COUNT VIII Alternative to Count VII -Unjust Enrichment 68. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 69. At Defendant's request, Plaintiff conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 70. Defendant received and accepted the benefit of said services provided by Plaintiff. 71. At all times material hereto, Defendant was aware that Plaintiff was providing the aforesaid services to Defendant and that Plaintiff expected to be paid for such. 72. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiff to provide said services and to incur damages. 73. At all times material hereto, Defendant was unjustly enriched by retaining the benefit of receiving said services without paying Plaintiff fair and reasonable compensation. 74. Allowing Defendant to retain the benefit of said services without paying fair compensation would be unjust. 75. By reason of the aforesaid unjust enrichment of Defendant at Plaintiffs expense, an implied contract exists between Plaintiff and Defendant and Defendant is obligated to pay Plaintiff the quantum meruit value of the services described in the exhibits attached hereto in the amount of $731.00. WHEREFORE, Plaintiff demands judgment against Defendant for $731.00 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff may be entitled. COUNT IX Breach of Contract 76. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 77. At the request of Defendant, Plaintiff issued its Business Catastrophe policy of insurance, policy number Q32 0171087, naming Defendant as the insured, a true and correct copy of the most recent renewal certificate for which is attached hereto, made a part hereof and marked Exhibit "I." 78. Pursuant to the terms and conditions of said policy, Defendant was required to pay earned premiums for the insurance coverage extended thereunder. 79. However, Defendant has failed to pay earned premiums in the amount of $616.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "J." 80. Defendant's failure to pay all earned premiums due Plaintiff for the extension of insurance coverage under the policy constitutes a breach of the policy. 81. Plaintiff has performed and complied with all terms and conditions required under said policy. 82. 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 November 29, 2010 the total amount of interest due to Plaintiff is $40.26. 83. Plaintiff is entitled to have the 6.00% interest charge continue to accrue as set forth above, from November 29, 2010 on down to the date of judgment in this matter. 84. Plaintiff has made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiff demands judgment against Defendant for $656.26 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff is entitled. COUNT X Alternative to Count IX -Unjust Enrichment 85. Plaintiff incorporates the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 86. At Defendant's request, Plaintiff conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 87. Defendant received and accepted the benefit of said services provided by Plaintiff. 88. At all times material hereto, Defendant was aware that Plaintiff was providing the aforesaid services to Defendant and that Plaintiff expected to be paid for such. 89. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiff to provide said services and to incur damages. 90. At all times material hereto, Defendant was unjustly enriched by retaining the benefit of receiving said services without paying Plaintiff fair and reasonable compensation. 91. Allowing Defendant to retain the benefit of said services without paying fair compensation would be unjust. 92. By reason of the aforesaid unjust enrichment of Defendant at Plaintiffs expense, an implied contract exists between Plaintiff and Defendant and Defendant is obligated to pay Plaintiff the quantum meruit value of the services described in the exhibits attached hereto in the amount of $616.00. WHEREFORE, Plaintiff demands judgment against Defendant for $616.00 together with the continually accruing interest charge at the statutory rate of 6.00%per annum from November 29, 2010, costs of suit and all other relief to which Plaintiff may be entitled. AMATO AND LESSA, P.C. By: Ronald Amato, Esq., Atty ID #32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 v~RIF~CA770N Christine Baughman, hereby states that she is the Executive Assistant in the Office of the President for the Erie Indemnity Company asAttorney-In Fact for F.rre Insurance Exchange, Plaintiffin this action, and verities that the statements made in the attached Complaint are true and correct to the best ofhis knowledge, information and belief. The undersigned understands that the statements herein are made subject to the penalties of I SPA C.S. ~'~90~ relating to unsworn falsification and authorities. _ ~_ ristine Baughman RTT INFORMATION PAGE ~~ PRIOR POLICY NUMBER - Q89.1600553 H AD7902 STEVEN L. FADS ERIE INSURANCE EXCHANGE 18457 Q89 1600553 H HAMMER EXPRESS INC . PO• BOX 60709 HARRISBURG PA 17106-0709 RENEWAL CERTIFICATE CORPORATION DAUPHIN CO .OTHER WORKPLACES_NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-2884395 RISK IDENTIFICATION NUMBER - 450659614 ITEM 2. THE POLICY PERIOD IS FROM 05/16/08~T0 05/16/09 AT THE INSUREDS MAILING ADDRESS. ITEM.3.A. WORI~RS'COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS. COMPENSATION LAW OF~THE STATES~LISTED HERE- VA. ITEM 3.B., EMPLOYERS LIAB3LITY 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 $100,000 EACH~ACCIDENT• BODILY INJURY BY DISEASE $500,000 POLICY~I;IMIT~ ' BOI}ILY INJURY BY DISEASE' $100; 000 EACH; EMPLOYEE .~ ITEM 3.C. OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE STATESy IF .ANY,. LISTED HERE: ALL STATES EXCEPT ~ND, OH,~ WA, WV, WY, . STATES DESIGNATED IN ITEM 3.A., ITEM 3.D: 'SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 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 SCHED_ULE,OF,OPERATIONS• .33,294 ~. EXPENSE CONSTANT 200 . ~ .TOTAL ESTIMATED ANNUAL,PREMI•UM $33,494 • - ~ - DEPOSIT•PREMIUM $33,494 'MINIMUM PREMIUM • '$519 •VA RATES, MIN.. PREM. AND/OR DEVIATIONS MAY CHANGE RETURNED PAYMENT FEES WILL' BE ADDED TO YOUR ACCOUNT. EXHIBIT . .. J .• PAGE O1 HOME OFFICE 03/08/08 SEE REVERSE SIDE WFS ** SCHEDULE OF OPERATIONS ** ITEM 4.. ~ CLASSIFICATIONS PREM BASIS RATE EST ST LOC CODE TOTAL-EST PER $100 ANNUAL NO ANN REMUN REMUN PREMIUM VA 001 8292 STORAGE WAREHOUSE NOC 1,441,400 2.77 $39,927 8810 CLERICAL OFFICE EMPLOYEES NOC 59,8.00 .I9 114 SUB-TOTAL 40,041 9898 EXPER~IENCB MOD, EFF 05/16/08, USING FACTOR .8900 4,405 C 9740 TERRORISM RISK INSURANCE ACT (TRIA) .046 691 OF 2002 - CERTIFIED LOSSES ' 0063 PREMIUM DISCOUNT~ENDORSEMENT 3,033 C 0032 LOSS CONSTANT' 0 TOTAL FOR VIRGINIA ~ ~ $33,294 TOTAL SCHEDULE OF ' OPERATIONS PREMIUM $33,294 ** SCHEDULE OF PRIMARY AND ADDITIONAL~I;OCATIONS~** LOC 001 •8258 RICHFOOD DR•, MECHANICSVII;LE~, VA 1'7106 *ENDORS EMENT SCHEDULE ** THIS POLICY INCLUDES: THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000308 (VA), WC-000414 (VA); WC-450602 (VA), WC=UF2106* (VA), WC-000419* (VA), WC-450401A* {VA), WC-990608* (VA), WC-UF4810* (VA), WC-UF4894 (VA), WC-990606 (VA) , WC=.0004~03* (VPi)'. ~ . . ~ ,• ** MI$CSLLANEOUS~INFORMATION PAGE, .SCHEDULE *-* ~~ :ENDORSEMENT 3'08 THE F.OLLOWING• IS .USED WITH ~WC0~0030.8: - ' OFF3CERS•- DARRELL•BALLARD -'PRESIDENT EARL MCCLEEREY ~- SECRETARY•/TREASURER Q89 1600553 RTT INFORMATION PAGE AD7902 STEVEN L. FADS HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA. 17106-0709 -~ PRIOR POLICY NUMBER - Q89 1600553 H ERIE~INSURANCE EXCHANGE 18457 Q89 1600553~H RE-ISSUED POLICY• • REASON FOR AMENDMENT- DUE TO RATE CHANGE CORPORATION DAUPHIN CO' OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED' FED ID # 23-2884395 RISK IDENTIFICATION NUMBER - 450659614 ITEM 2. THE POLICY PERIOD IS FROM 05/16/08 TO 05/16/09 AT THE INSUREDS MAILING ADDRESS. ITEM'3~:A: WORKEI2S~COMPENSATION~INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION'LAW OF THE STATES~LISTED~HERE- VA. .. ITEM 3..B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF. THE'POL'ICY•APPLIES•TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE .BODILY INJURY BY ACCIDENT $100,'000 EACH ACCIDENT , BODILY INJURY BY DISEASE $500,000 POLICY LIMIT . ~ BODILY INJURY BY DISEASE $100,000 EACH EMPLOYES ITEM 3~. C~. OTHER STATES INSURANCE PART THREE 'OF THE. POI;ICY~ APPLIES TO THE STATES, IF ANY, LISTED HERE-'ALL STATES EXCEPT ND,.OH, WA,•WV~, WY, STATES DESIGNATED IN ITEM 3.A., ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 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 SCHEDULE OF OPERATIONS 32,685• ' EXPENSE CONSTANT 200 TOTAL ,ESTIMATED ANNUAL~PREMIUM.' $32,885 ' ~ - ~DEPOSIT~PREMIUM $32,885 '- CHANGE IN PREMIUM FOR REMAINDER OF POLICY'PERI.OD $609:00 C MINIMUM PREMIUM $513 RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT. RTT FINAL AUDIT STATEMENT DUE TO CANCELLATION EFFECTIVE.07/13/08 AD7902~'STEVEN L: FAUS HAMMER• EXPRESS INC PO BOX 60709 HARRISBURG PA• 17106 0 ERIE INSURANCE EXCHANGE 18457 Q89 1&00553 H WHEN THIS POLICY WAS ISSUED, THE PREMIUM WAS BASED ON AN 'ESTIMATED' PAYROLL. RECENTLY, WE RECEIVED AN AUDIT WHICH~GAVE US .THE 'ACTUAL' PAYROLL: BELOW WE SHOW THE INFORMATION FROM THE AUDIT AND WS INDICATE THE 'ACTUAL' PREMIUM~AND THE 'ESTIMATED' PREMIUM AND HOW THE 'CHANGE IN PREMIUM' AFFECTS YOUR ACCOUNT. AUDIT PERIOD 05/16/08 TO 07/13/08 CANCELLED ST LOC CODECLASSIFICATIONS AUDITED RATE . NO ~ ~ PAYROLL PER $100 PREMIUM, ." , . ~ .. VA 001 829.2• STORAGE WAREHOUSE NOC 220,975 .2•.72 $6,011 • 8810 CLERICAL OFFICE EMPLOYEES NOC •14',242 .19 27 9898 EXPERIENCE MOD, EFF 05/16/08., USING FACTOR •.8900 664 C 9740 ~TERROR~ISM RISK INSURANCE ACT {TRIA} .0,44, 103 OE 2002 - CERTIFIED LOSSES • 0063 PREMIUM DTSCOUNT.ENDORSEMENT 3'7 C. • LOSS CONSTANT 0 " EXPENSE CONSTANT 32 ACTUAL~PREMIUM 5,472 ESTIMATED PREMIUM 32,8$5 CHANGE IN PREMIUM DUE TO AUDIT $27,413 C .i RETURNED PAYMENT FEES WILL $E ADDED TO YOUR ACCOUNT. THE ABOVE CHANGE HAS BEEN POSTED TO YOUR ACCOUNT. YOUR REGULAR MONTHLY ACCOUNT BILLING STATEMENT WILL REFLECT ANY REVISED INSTALLMENTS. PAGE OI HOME OFFICE 08/20/09 KEV .'' _ F, .+` ~.r ~, _ ',-} ~~/.V~ r. ~ i S~ '.~ ;Ht: c a _ ~2• r _ 4,i:.ii . .rj OUNT SUMMARY..z, ;~_'~~;='. =~:~=~ _~;r.~w..+ ~. .:~:~ ~; ERIE INSURANCE•OROUP Insund~and~Account Number: HAMMER EXPRESS'.INC t]89.1600553 A eM Number: AA7489 T11ps of PoNcy: WORKERS COMPENSATION Oate:of~Summa 7N9/201011:55 .Date Transaction Charges Credits ~ ~ Notes 13 51.16!2008 2008 renewal $33,494.00 14 5J46/2008. endorament -$609.00 5r~6rlooa latefee $1a.oo 7/13/2008 cancelled ~ -$27;250.00 . 7/13/Z008 re.instrnt $27,240.00 15 5/1612008 2008 audit _ -$27;413.00 rooessed 08/20109 512112008• . t -$3.698.00 _ 8111/2005 balance forward $8,373.00 riot ear Subtotals $69,117.00 -$58,970.00 Toial Famed Prernium $10,147.00 Famed premium owed on this policy EXHIBIT 0 ~~'~~ ~~;:~ ~- - -: ~ ~ ACCOUNT°S~UMM4RY=°,~_~~:==__ ~~~;~,~ _ .. ERIE iNSURANCE'CiROUP Insured:and Account Number: HAMMER EXPRESS?INC Q891600553 A ent Number: AA7489 T~jpe of PoN WORKERS COMPENSATION Date.of.Summa 7/1912010.11:55 Date Transaction Charges Credits ~ Notes 9 5/16!2007 2007 renewal $33,824:00 10 5/.16/2007 endorsment $3,735.00 1 i 51,1812007.. 2007! audit $22,152.00 recessed 08J08/08 '12 5/1612007 revlsed;audit =$13,779:00 recessed 08/21/08 5/1612007 ment -$3;209:00 6/21/2007 a ent -$3,449:00 7!23/2007 a merit -$3 850.00 _ _ 8/22/2007 ent -$3,688:00 9/20/2007 a merit -$3,603:00 10/26/2007 pa ent -$4;907:00 _ 11/21/2007 a ent -$6,132:00 12/21/2007 pa merit -$6;130:00 _ _ 1/24/2008 pa . eni -$8,139:00 3R/2007 balance.fonn-ard $3,548.00 rior ear " ~ ~ ~ $22,152.00 -$13;7.79.00 = $8,373:00 Subtotals ~ . $63,259.00 -$54;886.00 Total Earned Premium $8;37.3.00 Earned premium carried over to the foUowin ear t•~~ ~•' _:::{ ,_r.-:~: •~'- • ::~,,~ <::, A000~UNT~SUMMARY'.. _ =~= ;~;- _ _-_:~_ = ~- ERIE INSURANCE GROUP Insured and Account Number: HAMMER EXPRESS INC Q891600553 Agent Number:: AA7489 71-' of Polic : WORKERS COMPENSATION Date oi;8umma 7/,1912010`11:55 Date .Transaction' Charges Credits Notes . 4 5M 8/2006 2006 renewal $13;217.00 5 5/16126 endorsment $10,957.00 8 5/1612006 endoFsment $17,216.00 7 5Ht3/2006 dividends ~ -$1.018.00 8 5!16/2008 2006'audit $4;567.00 _ processed 08/12/07 5ht3/2006 t -$1;717.00 8/21/2006 a meet -$2,488.00 • 7120/2006 a ment -$5,085.00 ' ' 8/1712006 a ment -$3,405.00 9/21/2006 ment -$5.368.00 ^' 10/18/2008 ent -$8;192.00 11/24/2008 ent. -$5,778.00 12!22/2008 ~ • ~ ~ ent ~ -$6,271.00 _ 1/2512007 ent, -$6;083.00 8/14/2006 balance forward $998.00 prior year Subtotals $48,955.00 -$43;407.00 Total Earned Premium ~ $3,548.00 Earned remium carried over to the ._..__.... ..q._Y: r..: ~..>;: .r~. ,- .:7,+ ~~ e:i•_y~y{%:~ -o:r:ba?: r~i:• t"_.`T. .S:o- -,,:#li:~::°~!- . t. ~;::=, ~i4:>• ` _ ~ sty,,. !~, ~g ~_ ;r_~ ~ ~~ .~ (•~ - C1~ ~~'S-~~r.- n: 1~ ~~:.:~tLj v i' 'e -:~~=a; ' L.:?'ai~+ i •~ e_.n.ti ~~: -,;;,-.T _ _ - >ieN.!-.'. 1 Str Li i~~.....R •Y:1:' C.~I: L....~. ~. .. CCOUN~ SUM ARY=~•~~_~~i~.:~r:.L?'L:if•. :i~l~~'Y13~~: w~' M'l;~ia.•"1 ~~~~{t ~~ A _.~.:..:..~.M l..n. ,.~.. y G...... '1 L - •. ~+.... ......=.t =.•W...v:...-..F~~_:. r.K..ik_'~.3^.:J......w:iuw..,. ERIE INSURANCE t3ROUP Insured.and.Account.Number: HAMMER EXPRESS INC Q881600553 ent Number.. AA7489 T e of Po8 WORKERS COMPENSATION Date of Summa 7h 91201011:55 ,Date Transaction Charges Credits ~ .Notes' 1 5/16/2005 new.d sit $7,850.00 2 5!1612005. endorsment $3,885.00 ' 3 5116!2005 2005 audit $998.00 rocessed 08/10/06 tiJ28/2005 nt ~ -$520.00 _ 8N~112005 a nt•• -$1,293:00 9h1i2045 ~• ~nt -$1,211:00 10H7l2005 payment -$1.211:00 11/1712005 a ~t -$1;613:00 12/9/2005 payment -$2,773:00 1/12/2006 payment •$3,114:00 Subtotals ~ •$12;733.00 -$11,735.00 Total Earned Premium .$998.00 Famed Premium carried over to the I Ifoflowin ear RTT ERIE INSURANCE EXCHANGE ULTRAFLEX POOLICY RENEWAL CERTIFICATE !I AD7902 STEVEN L. FAUS ~ 05/16/06 TO 05/16/09 Q41 165.0546 H HAMMER EXPRESS INC _ PO BOX 60709 ~ • HARRISBURG PA 17106-0709 POLICY PERIOD BEGINS AND ENDS AT 12.01 A.M. STANDARD TIME AT THE STATED ADDRESS OF~THE NAMED INSURED. . THE INSURANCE APPLIES TO THOSE PREMISES DESCRIBED AS PER THE ATTACHED SUPPLEMENTAL DECLARATIONS. THIS IS SUBJECT TO ALL APPLICABLE TERMS OF THE ' POLICY AND ATTACHED FORMS AND ENDORSEMENTS DEDUCTI~BI;E (PROPERTY PROTECTION ONLY) - $ 500: COVERAGES:. DEPOSIT PROPERTY .PROTECTION -. AS .PER THE ATTACHED•SUPPLEMENTAL'DECLARATIONS PREMIUM 1. BLTI~LDINGS ~ ~ ~ - $~ 2. BUSINESS••PERSONAL PROPERTY AND PERSONAL PROPERTY OF OTHERS •• $ 'INCL• 3. INCOME PROTECTION $ 4. GLASS AND LETTERING ~ ~ $ 5. SIGNS, LIGHTS AND CLOCKS ~ $ , • LIMITS OF INSURANCE• ~ $~~ INCL PREMIUM BASIS - PAYROLL _ • EACH; OCCURRENCE LIMIT ~ $ 1,000',000 •• ~ • DAMAGE TO PREMISES ~ • RENTED TO YOU LIMIT $ 1,000,000 ANY ONE PREMISES MEDICAL EXPENSE LIMIT $ 5,000 ANY ONE PERSON •- PERSONAL & ADVERTISING INJURY LIMIT $ 1,000,000 ANY ONE PERSON OR ORGANIZATION ': GENERAL AGGREGATE LIMIT $ 2,000,000- • PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $ 2;000,000 .' • .., OPTIONAL ,COVERAGES ~ .SEE. NEXT 'PAGE • . TOTAL DEPOSIT PREMIUM - -~- - - $: 8,912. _- • .APPLICABLE FORMS,- SEE SCHEDULE OF FORMS EXHIBIT c C1T .03/10/08 ~• '~ I i .' 1 . ,+ . ~ I ~ I i OPTIONAL COVERAGES EMPLOYEE~BENEFIT LIABILITY - $.1000 DEDUCTIBLE ' $ 1,000,000 EACH CLAIM $ 2,000.,000 AGGREGATE RETROACTIVE DATE~05/16/2005 ENHANCEMENT ENDORSEMENT - WHOLESALERS ENDORSEMENT NON-OWNED AND HIRED AUTO LIABILITY'INS COV BODILY INJURY - $1,000.,000 PER PERSON $1,000,000 PER ACCIDENT PROPERTY DAMAGE - $1,000,000 PER ACCIDENT $ INCL $ INCL $ INCL 46 CONTINUED ON NEXT PAGE ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY RENEWAL CERTIFICATE AD7902 STEVEN L. FAUS 05/16/08 TO 05/16/09 Q41 1650546 H ,HAMMER" EXPRESS INC' • • PO`•'BOX 60709 ' ~ ' HARRISBURG PA 171'06-0709. ' ~' SUPPLEMENTAL DECLARATIONS ~ • ' LOCATION 1, BUILDING 1 . LOCATION OR PREMISES ,OCCUPANCY/OPERATIONS . RICHFOOD DR,'MECHANICSVILLE, COMMERCIAL WAREHOUSING INCLUDING HANOVER CO, VA. • 23111 OFFICE. ~ ~ ' ~ . • , ' INTEREST OF NAMED'INSURED IN SUCH~PREMISES~- TENANT •~• •• ' ~ PROPERTY PROTECTION • COVERAGES ~ CO-INS % AMOUNT ,OF' INSURANCE •• 1. BUI~LDIIJGS . 2. ~BtJSIIVESS PERSONAL PROPERTY AND 80 '• ~.$ 5, 0.00 ' 'PERSONAL PROPERTY OF• OTHERS 3. INCOME PROTECTION OCCURRENCE OPTIONAL COVERAGES - PROPERTY PROTECTION .~ C1T 03/10/08 SCHEDULE OF FORMS FORM NUMBER EDITION'.DATE DESCRIPTION ULF 03/01 ULTRAFLEX.PACKAGE POLICY • UF4768 10/07 * IMPORTANT NOTICE - REVISION TO ADDITIONAL • INSURED ENDORSEMENTS ~ • GU48 ~ 06/04 VIRGINIA AMENDA'T'ORY ENDORSEMENT ULRG 07%02 EXCLUSION - COLLAPSE .• UF3138*' .10•/.0.4 VIRGINIA IMPORTANT NOTICE -, NO FLOOD COVERAGE GU102 01/05 VIRGINIA AMENDMENT OF POLICY - TWO OR MORE • COVERAGE PARTS OR POLICIES WITH US~ • GWA• ~ 01/07' IMPORTANT INFORMATION FOR~VIRGINIA POLICYHOLDERS UF6807* 07/93 VIRGINIA NOTICE - ADDITIONAL COVERAGE AVAILABLE IL0985* O1/08•* DISCLOSURE PURSUANT TO TERRORISM • RISK INSURANCE ACT UF4810 03/08 * IMPORTANT NOTICE - POLICY SERVICE FEES FX0001 01/05 ULTRAFLEX COMMERCIAL PROPERTY COVERAGE PART GU110 05/Ob ULTRAFLEX COMMERCIAL PROPERTY ' ~ COVERAGE PART AMENDATORY ENDORSEMENT IL0952 01/08 * CAP ON~LOSSES FROM CERTIFIED ACTS OF TERRORISM UF4110 O1/OS * IMPORTANT'~NOTICE TO POLICYHOLDERS - TERROR~I~SM~ COVERAGE - PROPERTY CG0435 10/0.1 EMPLOYEE BENEFITS LIABILITY COVERAGE CG0448 01/06 VIRGINIA CHANGES - EMPLOYEE BENEFITS LIABILITY COVERAGE 46 CONTINUED ON NEXT PAGE I I ' I • i ~~ 'i ' I ERIE INSURANCE EXCHANGE • •ULTRAFLEX POLICY ~ • RENEWAL; CERTIFICATE 1 ' ,~ • ~ , 'AD7902 ~ STEVEN L.. FAUS 05/16/08 'TO05/16/09 Q4 Z, 1650546 H HAMMER ,EXPRESS INC ~ I PO BOX 60709 ' ' HARRISBURG PA• 17106-0709 '. SCHEDULE OF FORMS (CONTINUED) FORM NUMBER EDITION DATE DESCFt~IPTION UF4798 12/07 * IMPORTANT NOTICE ERIEPLACEABLE ' ENHANCEMENTS~ENDORSEMENTS ULLK UF4844 ULCL ULED GU32 CG0001 CG0179 IL0021 IL0138 GU124 FX0003 .UI;QN , CG2.1'4 7 UTAW ' CG2~1~67 . 000062 12/07 * WHOLESALERS ERIEPLACEABLE ENHANCEMENTS ENDORSEMENT 04/08 * .IMPORTANT NOTICE - NON-OWNED AUTOMOBILE; AND/OR HIRED: AUTOMOBILE LI•ABIL'ITY INSURANCE ,; ' 04/08 * ED AUTO LIABILITY NON-OWNED•AUTOS AND/•OR HIR _ INSURANCE COVERAGE 09/05 EXCLUSION - ASBESTOS 03/01 EXCLUSION -LEAD LIABILITY 10/01 COMMERCIAL GENERAL~LI~ABILITY.COVERAGE,FORM 02/03 VIRGINIA CHANGES • 11/85 EXCLUSION - NUCLEAR ENERGY LIABILITY 05/04 VIRGINIA CHANGES 12/07 * EXPANDED EXCEPTION TO POLLUTION EXCLUSION ' •Q1/05• ULTRAFI,EX EXTRA .LIABILITY COVERAGES • 04/06 ~ . EXCLUSION - PROFESSIONAL~LIABILITY 07/98 EMPLOYMENT-.RELATED PRACTICES EXCLUSION ,03/01 COVERAGE FOR ,PUNITIVE'~DAMAGES . • 04 / 02' FUNGI ' OR BACTERIA EXCLUSION . ~ 12/02 WAR LIABILITY EXCLUSION~~ ~, C1T' 03/10/08 . i • - i ' ~~ SCHEDULE OF FORMS (CONT•INUED}, FORM NUMBER EDITION DATE DESCRIPTION. .CG2170 O1/OS * CAP ON LOSSES FROM•CERTIFIED ACTS OF TERRORISM UF4111 01/08 * IMPORTANT NOTICE TO POLICYHOLDERS - TERRORISM COVERAGE - LIABILITY CG2229 11/85 EXCLUSION - PROPERTY ENTRUSTED t 46 '~ ~, RENEWAL CERTIFICATE AGENTS RATING WORKSHEET ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY ~AD7902 STEVEN L.•FAUS ' HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA 17106-0709 05/16/08 TO 05/16/09 Q41 1650546 H AGENTS RATING WORKSHEET LOC 1, BLDG 1 DEDUCTIBLE 500 ST VA COUNTY 342 PROT 09 COINT 21 CLASS 000963 RATE SPEC BUILDING ST YR CON 0000 AGREED AMT R/O •L/R •TENT~N RISK ID DONO'TO-BOER CSP 0000 PERILS COINS 0 ' SPEC RT 0.000 GRP2 RT 0.000 BLANKET RT F/V WH _ BLDG RMT 0 F/RATE 0.000 PREM MOD '0 ..000 BLDG PREM CONTENTS ST.VA YR CON AGREED AMT N • CSP 1212 'PERILS A C_OTNS 80 ' SPEC RT 0:34'7 GRP2 .RT 0:034 BLANKET •RT N, 'WH N ~ • CONT AMT 50.00 F/RATE 0.541 PREM MOD 1:.,000 CONT PREM LIABILITY PROTECTION. LIMIT 1000%2000. TYPE•DUAL PREM~MOD •1.000 • DL DED 0 - EXP RA'T'ING 001.000 ~• •YR• CON OOQO R•' LIAB R ACTUAL' MIN SQ ST CTY' T DL LE TR CLAS 'B' EXPOSURE RATE DED PREM •PREM O1 VA 342. S N N: 19. 000.963 P 1441400 05.650 8.1.44 198 THEFT ST VA 'CTY 342 CODE 2 DED 500 PREM MOD 1.000 AMT 5000 PREMIUM 0 50 50 . EMPLOYEE BENEFIT LIABILITY•COVERAGE •' -ST VA NO OF EMP' 10 LIMIT 1000 RATE .0:000. 'PREMIUM •297 .RETROACTI•VE• DATE• 05/16/200.5 - • 'ENHANCEMENT ENDORSEMENTS .ST CTY CLASS PREMIUM WHOLESALERS ENDORSEMENT VA 342 000963 150 ADDITIONAL.PROPERTY COVERAGES PREMIUM 99 NON,-OWNED AND/OR HIRED AUTO LIABILITY ST VA PREM MOD 1.000 TOTAL PREM 122 •'NON-OWNED AUTO Y BI LIMITS 1000/1000 PREM SO PD LIMIT 1000 PREM 17 HIRED AUTO Y BI LIMITS 1000/1000 PREM 44 PD LIMIT 1'000 PREM 11 C1T 03/10/08 ':~ ~` ~ •~ s.: ~ :~>~°=' ACC~OUIVT'SUIVlMARY - ' ~ ~ :; ~ - -- - - - _-- : - ERIE`INSURANCE~ GROUP Insured and Account~Number: HAMMER EXPRESS~INC Q41 1650546 A ant Number: ADT902 .ol:Poll UL7RAFCEX POLICY Date of Summa 7H 91201011:56 Date Transaction Charges Credits Notes 11 5h6/20t18 2008 renewal $8,912.00 5/16/2008 service cha a $10.00 5116!2008 late fee $10.00 5/16/2008 sarvk:e char a $5.00 7/13/2008 late fee -$10.00 7/13/2008 cancelled -$7,495.00 _ 5/22/2008 pa nt -$1,002.00 5/22/2008 balance fomard $1,868.00 prior year - ~ Subtotals $10;803.00 -$8,507:00 Total Eamed Premium - $2,296.00 Earned premium owed on this policy EXHIBfT a a r ~ ~... .. .~j.. .. {{ ''J is .• ~' ta:.- ~ ' ...' i.. :r,:; ~ ~,. ~ .lr , ~ ` - . e~ ts. - ACCO.UNT;SUMMARY: _~... ~.;. ~:~,,,.~ : _ - `._ ERIE INSURANCE GROUP Insured and Account Number: HAMMER~EXPRESS INC Q41 1650546 t Number: AD7902 o} PoUc : ULTRAFLEX POLICY Date of 8umrna 7/191201011:56 Date Transaction Charges Credos Nates . 7 5J16/2007 2007 renewal. $8,088.00 5/16noo7 service char a $20.00 8 511612007 endorsment $799.00 5h 6/2007 service charge $20.00 9 5/18/2007 2007 audit $4,921.00 rocessed 08/15108 10 5h6/2007 revised audit -$3;055.00 processed 08125!08 5N 812007 meet -$791:00 6/21/2007 meet -$851:00 7/23/2007 ment -$950.00 8/22/2007 payment -$912.00 9/20/2007 meet -$997:00 _ 10126!2007' a ment -$1,093.00 11121/2007 a ent -$1;368:00 1212112007 a ment -$1,370:00 1124/2008' a~ ment ~ -$1,377.00 9/17/2007 balance forward $782.00 rlor.year Subtotals $14,630.00 -$12,764:00 Total Eamed Premium $1,866.00 Eamed premium carried over to the foilowin ear ERIE INSURANCE ~3ROUP ACCOUNT SUMMARY Insured and Account Number: HAMMER EXPRESS iNC Q41 1850548 A ent Number: AD7902 T e of Pollc : ULTRAFLEX POLICY Date of Summa 7!19/201011:56 Date Transaction Charges Credits Notes 3 5H812006 2006 renewal $2,181.00 5H8/2006 service char a $5.00 4 5H6/2006 endorsment $2,710.00 5/18/2008 service char a $5.00 5 7N0/2006 endorsment $2,583.00 5116!2006 service char a $30.00 '6 511612006 2006 audit $782.00 06/28H0"""' 5118!2006 a ment -$283.00 6/21!2006 a ent -$511.00 7120!2006 a ment -$915.00 811712006 ment -$595.00 9121/2006 ment -$1,132.00 10/18/2006 a meet -$1,308.00 _ 11/2412006 payment -$1,222.00 12/22/2006 a ent -$1.329.00 1/25/2007 ent -$1,294.00 8/17/20011 balance forward $1,075.00 riot ear ' The audit amendment was incorrect ! tinted & issued to the insured on 9N4/07 as $1,240.00 (see attached). This rintin error does not chap the amount owed; because the accounts are correct showin the audit char a of $782.00 Subtotals __ I_ $9,371.00 -$8,589.00 - Total Eamed Pr ium e m $782.00 Eamed remium carried over t he _ _ _ _ _ foilowin ear t:: ~;~ .~~~ ° AC~COUNT~~SUMMARY_~~'°'~.~:,:_ ,,,,~~,...r _ ~> ERIE INSURANCE l3ROUP Insured:and~Account Number: HAMMER EXPRESS~INC~ t]41 1650546 A ent Number. ~ AD7902 . Type of ~iPotic : ULTRAFLEX~ POLICY Date.of Summa 7!19!2010.11:56 'D'ate Transaction Charges 'Credits. Notes 1 5118/2005 new d ~ ~ ft $2;339.00 5/.16!2005 service $18:00 2 5116/2005 2005 audit $1;075:00 rocessed OSh6/06 _ 6/2012005 pa ~ ent -$600.00 8/11/2005 payment -$307.00 _ 9H 1/2005 p ment -$289.00 _ 10/17/2005 ent -$289.00 1:1!16!2005 ~ ent -$387.00 .121912005 pa ment -$227.00 1712/2006 pa ent -$256.00 F I i Subtotals I $3,432.00 -$2,357.001 I _ r _~_ Total Eamed Premium $1,075.001 Eamed Premium carried over to the 1 I Ifollowin ear RTT INFORMATION PAGE AA7489 THE HESS AGENCY ' HAMMER EXPRESS INC _ PO BOX 6 0 7~0 9 HARRISBURG PA 17106-0709 W PRIOR POLICY NUMBER - Q92 51001'32 H ERIE INSURANCE COMPANY 14664 Q92 S100I32 H _ RENEWAL . CERTIFICATE CORPORATION DAUPHIN CO • OTHER WORKPLACES NOT SHOW2d•ABOVE - AS SCHEDULED FED ID # 23-2884395' RISK IDENTIFICATION NUMBER - 002976042 ' ITEM 2. THE POLICY PERIOD IS FROM 08/01/09 TO 08/01/10 AT THE INSUREDS• MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART.ONE.OF THE POLICY APPLIES TO. THE WORKERS CQMPENSATION LAW. OF THE.STATES•LISTED HERE- PA. _ ~ . ITEM •3.B. 'EMPLOYERS LIABILITY INSURANCE PART• TWO :OF THE: POI;ICY APPLIES TO WORK IN •EACH STATE I;I•STED: IN ITEM• 3.A. THE LIMITS OF OUR LIABILITY UNDER~~ PART TWO ARE BODILY INJURY.•BY ACCIDENT $100,000.EACH ACCIDENT ••• • • BODILY INJUItY••BY DISEASE $500, 000 POLICY: LIMIT BODILY•INJURY~BY DISEASE $100,000.EACH~EMPLOYEE ITEM 3~.:C_.• .OTHER •STATES INSURANCE- •PART THREE O_ F THE POLICY APPLIES TO THE STATES,• :I•F ANY, LISTED HERE- ALL STATES . EXCEPT ND, 'OEI, =FIA•, WY, STATES DESIGNATED IN ITEM'3.A.; ,~ ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. THE~PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RUI;ES, CLASSIFICATIONS•,.RATES AND RATING PLANS.~ALL INFORMATION REQUIRED BELOW•IS SUBJECT~TO VERIFICATION AND CHANGE BY AUDIT. ~ ~• ' ~• ~ . ~~ •SEE ATTACHED SCHEDULE OF~OPERATIONS~ 2 9,89.1- EXPENSE CONSTANT ~ 200•. . ~•' .• TOTAL ESTIMATED ANNUAL•PREMIUM $30,091 .CODE 0938 PA .EMPLOYER 'ASSESSMENT, 2.41$. $725 • . • DEPOSIT' PREMIUM $ 3 0 ; 816 MINIMUM'PREMIUM $1,254 ~ ~• .' . RETURNED PAYMENT FEES WILL BE EXHIBIT ~ ~- PAGE O1 HOME OFFICE 05/23/09 SEE REVERSE SIDE WFS ** S•CHEDULE OF OPERATI ONS ** ITEM 4. CLASSIFICATIONS PREM BASIS RATE• EST ST I;OC CODE TOTAL-EST PER $10 0 ANNUAL ENO ANN REMUN REMUN PREMIUM PA 001 0813 WAREHOUSING -'OTHER THAN•FURNITURE 380,000 10.54 $40,052 MOVING AND/OR STORAGE 0953 CLERICAL OFFICE~EMPLOYEES 50,900 .54 275 SUS-TOTAL ". 40,327 9898 EXPERIENCE MOD, EFF 08/01/09, USING FACTOR .8100 7,662 C 9740 TERRORISM ~ .036 155 9741 CATASTROPHE'. (OTHER THAN CERTIFIED ACTS .020 '86 • OF` TERRORISM). . 0063, PREMIUM DIBCOUNT`ENDORSEMENT . 3,015 C . 0032 LOSS•CONSTANT ~ ~ 0 T'OTAL,FOR.PENNSYLVANiA ~ ~ $29,891 TOTAL SCHEDUI;E OF • OPERATIONS PREMIUM $29,891 ** SCHEDULE~OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 •3500 INDUSTRIAL RD, .HARRISBURG, PA 17110 LOC 002 3900 INDUSTRIAL RD, HARRISBURG, PA 17110 LOC 003: 301 'RAILROAD AVE, CUMBERLAND CO, 3HIREMANSTOWN, PA 1701.1, .. *~*• ENDORSE•M~•EN.T SCH~E'D•UL•E~ **~ ~. :THIS POLICY INCLUDES'THESE.ENDORSEMENTS.AND SCHEDULES- WC-A4•/92, WC-.3.70310H (PA),,• WC-UF2106* (~PA) , WC~U~'4810* (PA) , . WC=.000421C* (PA) , WC.-370601 (PA) ,. WC-370602 '(SPA) ,' WC-370603A ,(PA).,, WC=UF4'446* (SPA) , WC-LTF3.OUI* (PA) , WC-UF3228* (PA) , WC-OOU419* (•PA)~, WC-00.0422A*. ,(PA•) ,. WC-UF5215* (PA) , WC-990602 (PA), WC=000403* (PA). Q92 5100132 CONTINUED ON NEXT PAGE INFORMATION PAGE AA7489 THE HESS AGENCY HAMMER EXPRESS I_NC :PO BOX 60709 :HARRISBURG'PA 17.106-0709 PRIOR POLICY NUMBER - Q92 510013.2 H ERIE INSURANCE COMPANY 14664 Q92 5100132 H ENDORSEMENT 3'10 TIME FOLLOWING IS •USED ~ WITH WC370310B - ~ ' NAM£ ~OF~.OFFICER - DARRELL BALLARD SOCIAL ,'SECURITY. # ~ 1'62-48'=1571 OFFICE HELD PRESIDENT SIGNATURE ~ ON FILE TYPE .OF CORPORATION S ~ OWNERSHIP INTEREST .51~ NAME;.OF OFFICER •EARL.MC CLEEREY :SOCIAL•.SECURITY # 294'-42=2448 • OFFICE~~FiELD~, ~ SECRETARY/TREASURER ;SIGNATURE. • ON FI~L$ • TYPE :OF CORPORATION S ' : ~ . ' $ ; OWNERSHIP• •I'NTEREST 4 9.~. , • • .' . PAGE 02 HOME OFFICE 05/23/09 ~ WFS I ~~ i .t.. RTT INFORMATION PAGE AA'74 8 9 THE HESS AGENCY HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA 17106-0709 1 PRIOR POLICY NUMBER -,Q92 5100132 H ERIE INSURANCE COMPANY 14664 Q92 5100132 H RENEWAL CERTIFICATE CORPORATION DAUPHIN CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-2884395 RISK IDENTIFICATION NUMBER - 002976042 ITEM 2. THE; POLICY PERIOD IS FROM 08/01/09 TO 08/01/10 AT THE INSUREDS' MAILING ADDRESS. ITEM 3..A. WORKERS•COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS 'COMPENSATION I~LW OF THE STATES FISTED HERB- PA. ITEM 3..B. EMPLOYERS I;IABILITY INSURANCE- PART TWO OF THE:POL'ICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR•LIABII;ITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT ~, BODILY II3JURY: BY DISEASE ~ $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100;000 EACH~EMPLOYEE ITEM 3:. C:. OTHER STATES INSURANCE- PART THREE• OF 'THE 'POLICY ~APPLIES~ TO THE STATES,• IF ANY, LISTED HERE- ALL STATES EXCEPT ND', OH, WA, WY,•STATES DESIGNATED IN ITEM 3:A., ITEM 3.D. SEE•ATTACHED ENDORSEMENT SCHEDULE ITEM 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 SCHEDULE OF~OPERATIONS. 29,603 . EXPENSE :CONSTANT •200 TOTAL ESTIMATED ANNUAL. PREMIUM $29,803 CODE 0938 PA EMPLOYER ASSESSMENT 2.41 $.718 . DEPOSIT PREMIUM $30,521 MINIMUM PREMIUM $1,254, ~ ~ . RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT. PAGE O1 HOME OFFICE 05/29/09 SEE REVERSE SIDE L3A ** SCHEDULE OF OPERATI ONS** ITEM 4. CLASSIFICATIONS PREM BASIS RATE EST ST LOC CODE ~ TOTAI;-EST PER $100 ANNUAL • NO ~ ,' ANN REMUN REMUN PREMIUM , PA 001 0813 WAREHOUSING -.OTHER THAN FURNITURE 380,000. 10.,54 $40,052 MOVING AND/OR STORAGE ' 0953 CLERICAL OFFICB EMPLOYEES 50,900 .54• 275 SUB-TOTAL 40,327 9898 EXPERIENCE MOD, EFF 08/01/09, USING FACTOR .8020 7,985 C 9740 TERRORISM .036 155 97.41 .CATASTROPHE (OTHER, THAN°CERTIFIED ACTS .020 86 OF TBRRORISM}.'•. ~ ~ ' 0063 PREMIUM DISCOUNT ENDORSEMENT 2,980 C 0032 LOSS .CONSTANT ~ 0 • .TOTAL FOR PENNSYLVANIA $29,603 TOTAL SCHEDULE OF. OPERATIONS 'PREMIUM .~ $29,603 .• ~ **.SCHEDULE•OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 3500 INDUSTRIAL RD, HARRISBURG, PA 17110 , LOC 002 3900 INDUSTRIAL RD, HARRISBURG, PA 17110 LOC 003 '.•301 RAILROAD AVE, CUMBERLAND CO`, SHIREMAIJSTOWN, PA 17011 • ** E N D O .R' S E M ~E ~N.T S. C H ~E, D U L. E ** . .THIS POLICY. INCLUDES THESE ~ENDORSEMENTS.AND SCHEDULES- WC-A4/92, WC-370310B' (PA), WC-UF2106* (:PA)~, 'WC-UF4810* ,{PA),, WC.-00.04210*~ (~PA)., WC-3?0601 (PA) , ' WC-370602 (PA) , ;WC-3706,03A (PA') , ~WC-LTF4`446*~ (PA};; WC-UF3001*~ (PA) , WC-UF3228* (PA), WC-000419* (PA); WC-a00422A* (PA'),~ WC-UF5215* (~PA),~ WC-990602 (PA), WC-000403* (PA}.~ ,' Q92 5100132 CONTINUED ON NEXT PAGE' INFORMATION PAGE PRIOR POLICY NUMBER - Q92'S100132 H AA7489 THE HESS AGENCY HAMMER EXPRESS INC' PO BOX 60709 HARRISBURG PA 17106-0709• ERIE INSURANCE COMPANY 14"664 Q92 5100132 H . ENDORSEMENT 370 • ' THE' •FOLLOWING IS USED~~ WITH WC37.03108 - ' NAME:OF OFFICER ~ DARREL'L BALLARD • .SOCI•AL' SECURITY # ~ 162-48=1571 •OFFICE HELD •PRESIDENT SIGNATURE ~ ON•FILE TYPE OF CORPORATION S $ OWNBRSHIP~INTEREST 51$ NAMB•OF OFFICER ~ BARL MC CLEEREY SOCIAL. SECURITY~# 294-42=2448 • • OFFICE HELD ~ SECRETARY/TREASURER •SIGNATURE ON' FILE • •TYPE~ OF' CORPORATION _ S $ OWNERSHIP •INTEREST 49$ ~ • PAGE 02 HOME OFFICE-05/29/09 - , RTT INFORMATION PAGE AA7489 THE HESS AGENCY HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA 17106-0709 :, AMENDMENT O1 *** EFFECTIVE 08/Oi/09 ***.AT.TACH THIS TO YOUR POLICY REASON FOR AMENDMENT- ELIMINATED LOCATION & AMENDED PAYROLL CORPORATION DAUPHIN CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID~# 23-2884395 RISK IDENTIFICATION NUMBER - 002976042 ITEM 2. THE POLICY PERIOD IS FROM 08/01/09 TO 08/01/10 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. 'WORKERS•COMPENSATION INSURANCE-•PART ONE; OF•THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STP;TES,.LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABI~LITY.INSURANCE- PART TWO OF`THE.POLTCY APPLIES TO WORK IN EACH STATE.LISTED IN ITEM 3..A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY ,INJURY BY DISEASE .$500,000 POLICY LIMIT ,BODI•LY. INJURY.BY:DISEASE $100.,000 EACH EMPLOYEE ITEM•3.C.~ OTHER STATES INSURANCE- PART THREE OF THE POLICY .APPLIES :TO THE STATES, IF• ANY, LISTED THERE- ALL. STATES EXCEPT ND, 'OH, WA, •WY, STATES• DESIGNATED IN ITEM 3.A., ITEM 3.D. SEE~ATTACHED ENDORSEMENT SCHEDULE ITEM 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 SCHEDULE OF OPERATIONS '15,945 EXPENSE .CONSTANT ~ 200 ' TOTAL ESTIMATED ANNUAL: PREMIUM $16,.145 CODE 0938 PA EMPLOYER ASSESSMENT• 2..4'1 $389 • DEPOSIT. PREMIUM $16,534 CHANGE IN PREMIUM FOR REMAINDER OF -POLICY PERIOD $13-,:987.00 C 'MINIMUM. PREMIUM $1,254 ' PRIOR 'POLICY NUMBER - Q92 5100132 H ERIE INSURANCE COMPANY 14664 Q92 5100132 H RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT. THE ABOVE CHANGE HAS BEEN POSTED TO YOUR ACCOUNT. YOUR REGULAR MONTHLY ACCOUNT BILLING STATEMENT WILL REFLECT ANY REVISED INSTALLMENTS. PAGE O1 HOME OFFICE 07/09/09 SEE REVERSE SIDE AFDLM3 ** S C H E D U L E O' P O P E R' A T I O N S ** ITEM 4.. CLASSIFICATIONS .' PREM BASIS RATE EST ST LOC CODE ~ ~ TOTAL-EST PER $.100 ANNUAL NO ANN REMUN REMUN. PREMIUM PA 001 **** CLASS 0813 CHANGED EFF 08/01/09 0813 WAREHOUSING - OTHER THAN FURNITURE 200',000 10.54. $21•,080 MOVING~AND/OR STORAGE • 0953 CLERICAL OFFICE SMPLOYEF~S 50;900 .54 275 SUB-TOTAL ~ 21,.355 9898 EXPERIENCE MOD, EFF 08/01/09, USING FACTOR .8020 4,228~.C 9740 TERRORISM ~ .036 ,. 90' 9741 CATASTROPHE (OTHER THAN. CERTIFIED'ACTS~ .,020 50 OF TERRORISM} 00.63 PREMIUM DISCOUNT PND.ORSEMENT ~ 1, 322 C • 0032 LOSS CONSTANT ~ 0. TOTAL FOR PENNSYLVANIA ~' $15,945 TOTAL SCHSDUL'E .0F , • OPFRAT~IONS PREMIUM .' . ~ '$15 ,.94 5 ~. ~** SCHEDULE; OF PRIMARY•AND ADDITIONAL LOCATIONS ** LOC 001 3500 INDUSTRIAL RD, HARRISBURG, PA 17110 ' LOC 002 3900 INDUSTRIAL RD, HARRISBURG, PA 17110 ' •_ ** E ~N•D O R S E'M E N T SCHEDULE ** • THIS'POLICY INCLUDES THESE ENDORSEMENTS AND~SCHEDULES-.WC-A4/.92~, WC-3703~1UB (PA};,- WC=UF2106 (PA} , WC-UF4810 {pA) , WC-:0,004~2•TC~ (PA~) , WC-37.0601 (PA).; WC=370602 (PA), WC-370603A (PA), WC-UF4446 (•PA).,.•WC=UF3001 (PA), WC-UF3228 (PA) ,, WC-.000419 (PA) , WC-000422A (PA) ,• .WC=UF5215 (PA)_~, WC-990602 (PA) , WC-000403 (PA).. Q92 5100132 CONTINUED ON NEXT PAGE INFORMATION'PAGE PRIOR POLICY NUMBER - Q92 5100132•H AA7489 THE HESS AGENCY ERIE INSURANCE COMPANY 14664 Q92 5100132 H HAMMER EXPRESS ~INC P.0 BOX 60709 ~ , • • HARRISBURG PA 1.710 6 _ 0 7.0.9 .. ' ENDORSEMENT• ,370 THE,FOLLOWING.,IS USED WITH.WC3'7~0310B - • NAME OF' OFFICER, ~ .DARRELL~'BALLARD OFFICE HELD PRBSIDENT~ ' '~•NAME' OF. OFFICER EARL' MC CLEEREY OFFICE HELD SECRETARY/TREASURER PAQE 02 HOME OFFICE 07%09/09 AFDLM3 RTT INFORMATION PAGE 0 PRIOR POLICY NUMBER - Q92 5100132 H AA7489 THE HESS AGENCY HAMMER EXPRESS INC PO BOX 60709 HARRISBURG 'PA 17106-0709 ERIE INSURANCE COMPANY 14664 Q92 5100132 H AMENDMENT 02 *** EFFECTIVE 08/01/09 *** ATTACH THIS~TO YOUR POLICY • REASON FOR AMENDMENT- DECREASED~PAYROLL CORPORATION DAUPHIN•'CO • OTHER WORKPLACES NOT SHAWN ABOVE - AS SCHEDULED FED ID # 23-2884395 RISK IDENTIFICATION NUMSSR - OQ2976042 ITEM 2. THE POLICY PERIOD IS FROM 08/01/09 TO OB/O1/10 AT THE INSUREDS MAILING ADDRESS. ITEM 3'.A. :WORKERS 'COMPENSAT•ION~INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS CbMPENSATION I~AW1 OF THE• STATES LISTED: HERE- PA .. • ITEM 3..8. 'EMPLOYERS LIABILITY INSURANCE= PART TWO OF` THE POLICY APPLIES•TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR.•I;IABILITY UNDER PART TWO ARE • BODILY INJURY BY'ACCIDENT $100,000 EACH.ACCIpENT • BODILY INJURY BY DISEASE $500,000 POLICY LIMIT • • ~ BODILY INJURY BY DISEASE $1.00,000 EACH EMPLOYEE ITEM 3.:C. OTHER'STATES INSURANCE- FART THREE•OF THE POLICY APPLIES TO THE STATES, IF ANY, L'ISTED• HERE- AI;Z; S'T'ATES EXCEPT ND; OH, WA, WY, STATES DESIGNATED •IN .3TEM' 3 .A.•, ' ITEM 3:D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 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 VER•IF'ICATION 'AND CHANGE BY AUDIT: • ~ r• • •SEE:ATTACHED SCHEDULE OF OPERATIONS 10,254 •~EXFENSE CONSTANT 200 • - ~ TOTAL ESTIMATED ANNUAL PREMIUM ~ $10,454 •CODE• 0938• • , PA EMPLOYER ASSESSMENT 2::'4.1$' $252 • ~ •DEPOSIT PREMIUM $10,706 ••CHANGE IN PREMIUM FOR REMAINDER•OF POLICY•PERIOD $5,828.00 C 'MINIMUM PREMIUM $1,254 i RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT. THE ABOVE CHANGE HAS BEEN POSTED TO YOUR ACCOUNT. YOUR REGULAR MONTHLY ACCOUNT BILLING STATEMENT WILL REFLECT ANY REVISED INSTALLMENTS. r PAGE O1 HOME OFFICE 08/24/09 SEE REVERSE SIDE JD8 ** SCHEDULE OAF OPERAT I ONS ** ITEM 4. CLASSIFICATIONS PREM BASIS RATE' EST ST LOC CODE • TOTAL-EST PER $100 ANNUAL Np ANN REMUN REMUN PREMIUM PA 001 **** 'CLASS 0813 CHANGED EFF 08/01/09 ' 0813 WAREHOUSING,- OTHER THAN FURNITURE 125,000 10.54 $13•;'175. MOVING AND/OR STORAGE 0953 CLERICAL OFFICE•EMPLOYEES~ 50,900 .54 27:5 SUB=TOTAL 1.3,450 9898 EXPERIENCE MOD, EFF 08/01/09, USING FACTOR .8020 2,663 C 9740 TERRORISM ~ •:036 63 9741 CATAST1tOPHE (OTHER THAN ~CF.SRTIFIED ACTS .020 35;. . OF TERRORI SMj~ 0063 PREMIUM DISCOUNT ENDORSEMENT '631 C ' 0032 LOSS CONSTANT ~ _ •0 TOTAL FOR PENNSYLVANIA $10,254 TOTAL SCHEDULE OF OPERATI013S PREMIUM $10,254 ** SCHEDULE~OF PRIMARY AND ADDITIONAL. LOCATIONS ** LOC .001 3500 INDUSTRIAL RD, HARRISBURG, PA 17110 . LOC 002 3900 INDUSTRIAL RD, HARRISBURG, PA 17110 • ** E N D O R S E M E N T S.C-H E~D~U L•: E' **• ' ~ THI~S..POLICY INCLUDES THESE ENDORSEMENTS .AND' SCHEDULES- .WC-A4~/92, WC'-3703TOB' (PA}~, WC-UE'2106 (PA} , ~WC-UF4~810~ `(~PA) , WC=00042~1C (PA) ; WC-370601 (~PA} , WC-370602 '{PA)., WC=370603A (PA} , WC-UF4446 (PA}., •WC'-UF3001 (SPA) .; WC-UF3228 (SPA} , WC=0004.1.9 (PA} , WC-000422A {PA) , WC-UFS215 (~PA) ; 'WC-990602 (PA) , WC-000403 Q92 5100132 CONTINUED ON NEXT PAGE INFORMATION PAGE PRIOR-POLICY NUMBER•.- Q92 5100132 H AA7489.'THE HESS AGENCY ERIE INSURANCE COMPANY 14664 Q92 5100132 H HAMMER EXPRESS INC PO. BOX' 60.7.09 ~ ~. ~ . . 'HARRIS$URG PA 1'7~1~06-0709 ~ • . . ENDORSEMENT 370 . ;~ ' THE FOI;LOWING IS; USED WITH WC3.70310B: •- :NAME; OF 'OFFICER ~ DARRELL BALI;ARD:• .OF.FICE' HELD' PRESIDENT ~ • NAME~OF"OFFICER ~ EARL MC CLEEREY OFFICE HELD SECRETARY/TREASURER PAGE '02 HOME ~OFF~ICE 08/24/09• JD8 ,. RTT INFORMATION PAGE IO _ PRIOR..POLICY NUMBER .- _Q92 .5100132. H~ AA7489 THE HESS AGENCY ERIE INSURANCE COMPANY 14664 Q92 5100132 H HAMMER EXPRESS INC P,0 BOX 60709 HARRISBURG PA 17106-0709 AMENDMENT 03 *** EFFECTIVE 08/01/09 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- DECREASED PAYROLL CORPORATION DAUPHIN CO OTHER'WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-2884395 RISK IDENTIFICATION NUMBER - 002976042 I.TfiM 2. THE POLICY PERIOD IS FROM 08/01/09 TO 08/01/10 AT THE INSUREDS MAILING ADDRESS. ITEM;3.A. WORKERS COMPENSATION INSURANCE= PART ONE OF THE-POLICY APPLIES TO THE WORKERS~COMPENSATION LAW 'OF THE~STATES LISTED HERE- PA. ITEM 3:B. EMPLOYER3~LIAHILITY INSURANCE- PART TWO. .OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3:A. THE LIMITS OF OUR:LIABI~LITY• UNDER PART TWO•ARE BODILY INJURY~BY ACCIDENT $100,000•EACH ACCIDENT BODILY INJURY BY .DISEASE $500,000 POLICY LIMIT .BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. •OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE STATES; IF ANY, 'LISTED .HERE- ALL~STATES EXCEPT ND, OH, WA, WY, 'STATES DESIGNATED IN ITEM 3~.A., ~~ ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. THE PREMIUM FOR THIS•POLICY WILL BE DETERMINED BY OUR MANUALS~OF RULES, CLASSI'FICATIONS', RATES AND RATING PLANS.. ALL INFORMATION REQUIRED BELOW~IS SUBJECT TO~VERIFICATION AND•CHANGE BY AUDIT. ~ • SEE ATTACHED•SCHEDULE OF OPERATIONS 2,127 . ~ EXPENSE CONSTANT 200 • ~ TOTAL ESTIMATED~ANNUAL PREMIUM' $2,327 . CODE 0938. PA EMPLOYER ASSESSMENT 2.4;1 .$56 DEPOSIT PREMIUM $2,383 ' ~~•CHANGE IN PREMIUM FOR REMAINDER OF POLICY 'PER'IOD ~ $8,323.00 C MINIMUM PREMIUM $•1,254 RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT. THE ABOVE~CHANGE HAS BEEN POSTED TO YOUR ACCOUNT. YOUR REGULAR MONTHLY ACCOUNT BILLING STATEMENT WILL REFLECT ANY REVISED INSTALLMENTS. PAGE O1 HOME OFFICE 10/28/09 SEE REVERSE SIDE CPDJC ** S CHEDULE OF OPERAT IONS ** ITEM 4. CLASSIFICATIONS PREM BASI S RATE EST ST LOC CODE TOTAL-EST PER $100 ANNUAL NO ANN RBMUN REMUN PREMIUM PA 001 **** CLASS 0813 CHANGED EFF OB/Ol/09~ ~ ' . 0813 WAREHOtJ$ING - OTHER THAN FURNITURE 25,000 10.54 $2,635, MOVING AND/OR STORAGE ~ ~ ' **** CLASS 0953 CHANGED EFF 08/01/09 0953 CLERICAL OFFICE EMPLOYEES IF ANY .54 ~ .0. SUB,-TOTAI; 2,635 •9898. EXPERIENCE•MOD, EFF 08/01/09,, USING FACTOR ,8020 .522 C 9740 TERRORISM .036 9 9,741• ' CATASTROPHE (OTHER "THAN CERTIF.IED~ ACTS ".020 5 ' OF TERRORISM) ' ' 0032 LOSS :CONSTANT ~ "~ ~ 0 TOTAL FOR•PENNSYLVANIA $2,127 TOTAL SCHEDULE~OF _ . "OPERATIONS PREMIUM , ' ~** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 3500 INDUSTRIAL RD, HARRISBURG, PA 17110 LOC 002• .3900 INDUSTRIAL RD, HARRISBURG, PA 17110 $2,127 ** END 'O R' S E. M E N T S, C H E D U' L E '** ' ' i THIS POLICY INCLUDES THESE ~ENDORSEMENTS~AND~SCHEDULES- WC-A4/92~, WC-37,03•lOB, (PA~) , WC=UF2106~ (PA~) ,. WC=UF444.6 (PA) , WC-UF4810 (SPA) ,~ WC=000421C (•PA),', .WC-370601 (PA) , WC-3:7.0602 (•PA) , WC-37U603A (PA)•.,• WC-UF3001: ~ (PA) , WC-UF3228 {PA) ,, WC-000419 ~(~PA) , WC-000422A (PA),, WC-UF52fi5• (PA) ; 'WC-00.0403 (PA) . Q92 5100132 CONTINUED ON NEXT PAGE INFORMATION PAGE PRIOR POLICY NUMBER - Q92 5100132 H . AA7489 THE HESS~AGENCY ~ ERIE INSURANCE COMPANY 14664 Q92 5100132 H~. • HANA4ER EXPRESS INC , _~ PO BOX 60709 HARRISBURG, PA 17106-0,'709 ENDORSEMENT 370 THE FOLLOWING IS° 'USED 'WITH WC3,70310B ~- NAMB~OF OFFICER DARRELL BALLARD . OFFICE HELD PRESIDENT . NAME OF OFFICER EARL MC.CLEEREY .OFFICE HELD ~ ~ SECRETARY/TREASURER ~- .' FAGE 02 HOME OFFICE 10./28/09 .' • ~ ..~ CPDJC ', sir ~~::~...-.~1~w~ - - ~~ ERIEINSURANCEGROUP , 1 E ~~"' ~, ':.~i ~'~ 4~r:: ~-'a'.:1 :~... l~:Y ~c ACC'O.UNIT,~SUMIIIIARYr:~-,~_F:~:~,a:=,;. _. =- .::- - ,.,-``L , ~::-`~. Insured and Account Number: HAMMER~EXPRESS~INC (392 5100132 Agent Number: AA7489 T~.of Polic : WORKERS COMPENSATION Date of Summa 7/,191201011:58 Date Transactbn Charges Credits: Notes 8 8/1/2009 2009 renewal $30,816.00 7 8/1/2009 endorsment ~ -$295:00 $30,816.00 - $295.00 = $30,521.00 8 8/1/2009 endorsment -$13,987.:00 . 9 8/1!2009 endorsment -$5;828.00 - 6/1/2009 late fee $1o.oa 10 8/1/2009 2009 audit -$8;323.00 811/2009 late fea $10.00 ~ _ 8/1/2009 cancelled -$670.00 12H4/2009 t -$159.00 1/17/2010 a t -$160.00 _ 2h 812010 payment -$265.00 5(23/2009 balance forward $141.00 ear i I . i Subtotals f $30,836.00 -$29,546.00 I Total Eamed Premium j $1,290.00 Earned premium owed on this policy I EXHIBIT . -,:,~;s~:~J. -' -_ -_ .-.F: =~ ACCC}U.NT~SUMMARY~~I.:~d --• _ . - ~=-~ - '- - ERIE INSURANCE;OROUP Insured;and Account Number: HAMMER.EXPRESS•.INC •Q92.5100132 ent Number: AA7.489 T of Polio :• WORKERS COMPENSATIQN Date of Summa 7119120!011:57 Date Transaction Charles Credits • Notes -1 8/1/2008 2008 renewal $34,036.00 2 8/1/2008 endotsment $878.00 . $34,036.00 +:5876.00 = $34,912.00 3 811/2008 endorsment -$7;669.00 8/1/2008 Iate fee $10.00 4 8/1!2008 dividends -$6,322:00 5 811/2008 2008~audft $2,238.00 procslssed:11h3/09 9/17/2008 menf -$2,097:00 10/30/2008 ment -$3,134.00 1/12/2009 ment •$1.566.00 415/2009 a ment -$2.123:00 5JZ412008 cxedit balance -$14',108:00 from rior ear • I Subtotals ~ $37,160.00 -$37,019.00 _ Total Earned Premium $141.00 Earned premium carried over to the followi ear RTT RENEWAL CERTIFICATE AA7489 THE HESS AGENCY HAMMER EXPRESS ,INC ,. . PO BOX ~60~709 HARRISBURG PA. 17106-0709 ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY • i 08/01/09 TO OB/O1/10 Q44 0151498 H POLICY PERIOD. BEGINS AND ENDS AT 12:.:01 A.M..STANDARD TIME AT THE. STATED ADDRESS OF THE NAMED INSURED. THE INSURANCE APPLIES TO THOSE PREMISES DESCRIBED AS~PER THE ATTACHED SUPPLEMENTAL DECLARATIONS. THIS IS SUBJECT TO ALL APPLICABLE TERMS OF THE POLICY AND ATTACHED FORMS AND ENDORSEMENTS DEDUCTIBLE•~'(PROPERTY PROTECTION ONLY)- $ 500. • COVERAGES::: .• DFPO$IT PROPERTY PROTECTION - AS PER`THE ATTACHED SUPPLEMENTAL DECLARATIONS .PREMIUM • 1. BUILDINGS ~ $ ~~ 2. BUSINESS PERSONAL PROPERTY AND PERSONAL PROPERTY OF :OTHERS $ INCL 3. INCOME PROTECTION ~ $ 4. GLASS AND LETTERING .$ 5. SIGNS, LIGHTS AND CLOCKS ~ $ • LIMITS OF INSURANCE ~ $ INCL PREMIUM :BASIS - 'PAYROLL ' ' EACH.000URRENCE LIMIT $•Y,000•,000 DAMAGE TO PREMISES _ 'RENTED~TO YOU LIMIT $ 1,000,000 ANY ONE PREMISES, `MEDICAL. EXPENSE LIMIT $ 5,000 ANY ONE PERSON PERSONAL & ADVERTISING•INJURY LIMIT $ 1,000,000 ANY ONE PERSON OR ORGANIZATION GENERAL~.AGGREGATE LIMIT $ 2,000.000 PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $ 2,000,000 •• OPTIONAL. COVERAGES- '• EMPLOYEE BENEFIT LIABILITY - $1000 DEDUCTIBLE $ 1,000,0.00 EACH•EMFL07CEE . '$ 2'; 0 0 0, 0 0 U AGGREGATE - RETROACTIVE`.DATE 08/01/1999 ENHANCEi+RENT~ENDORSEMENT - WHOLESALERS ENDORSEMENT ADDITIONAL.INSURED•-- OWNERS, LESSEES OR CONTRACTORS (ULRH) . TOTAL DEPOSIT PREMIUM - - - - - APPLICABLE FORMS - SEE SCHEDULE OF FORMS EXHIBIT .• ~ $ INCL $ INCL $ INCL $ 7,478. ., ~~ DJ2 05/28/09 ' SUPPLEMENTAL DECLARATIONS LOCATION 1, BUILDING 1 LOCATION OF PREMISES ~ 'OCCUPANCY/OPERATIONS 3500 INDUSTRIAL RD, HARRISBURG, CO1~iERCIAL WAREHOUSE - INCLUDING DAUPHIN CO, PA 17103 OFFICE • (RFD: HARRISBURG}' INTEREST OF NAMED INSURED IN SUCH PREMISES - TENANT PROPERTY PROTECTION 'COVERAGES .~ CO~-INS %• AMOUNT OF INSURANCE 1. BUILDINGS ~ ~ 2.. BUSINESS PERSONAL. PROPERTY AND 80, ~ $ ,25;000 • PERSONAL•PROPERTY OF OTHERS 3. INCOME PROTECTION OCCURRENCE OPTIONAL COVERAGES - PROPERTY PROTECTION I;OS.S 'PAYEE ~. SOVEREIGN BANK . - ATTN: • MAZL• CODE ~60-57.1-CM1 _ ' ~ . 61'9. •ALEXANDER ~RD' . . PRINCETON NJ' 08540-6000 ~, r 98 CONTINUED ON NEXT PAGE RENEWAL CERTIFICATE AA7489 THE HESS AGENCY .HAMMER EXPRESS INC PO -BOX 60709 HAItRISBURG.PA 17106-0709 ERIE .INSURANCE EXCHANGE ULTRAFLEX POLICY 08/O1/09.T0 08/01/10 'Q44 01514'98~H SUPPLEMENTAL DECLARATIONS ' LOCATION 2, BUILDING 1 ' LOCATION-OF-PREMISES ~ OCCUPANCY/OPERATIONS 3900 .INDUSTRIAL RD, HARRISBURG; WAREHOUSE - CGL~-COVERAGE PART; ONLY DAUPHIN. CO, PA 17103' (RFD: HARRISBURG) - .. • INTEREST OF NAMED INSURED ~IN•'SUCH PREMISES - TENANT. • .PROPERTY PROTECTION • . 'COVERAGES CO-INS ~ 'AMOUNT OF INSURANCE 1. BUILDINGS; ~ - . 2. BUSINESS PERSONAL PROPERTY•AND PERSONAL PROPERTY OF OTHERS 3. INCOME PROTECTION OCCURRENCE r DJ2 05/2$/09 S SUPPLEMENTAL DECLARATIONS • - LOCATION 3, BUILDING 1 ' L'OCATION•OF PREMISES OCCUPANCY/OPERATIONS ' 301 RAILROAD•AVE, SHIREMANSTOWN~, ,WAREHOUSE - CGL`=COVERAGE .PART ONLY CUMBERLAND CO, •PA 17011 (RFD: SHIREMANSTOWN) INTEREST OF NAMED. INSURED.IN•SUCH PREMISES - TENANT .PROPERTY PROTECTION - ' COVERAGES C0- IIJS' ~ AMOUNT' OF INSURANCE '1. BUILDINGS 2 ..:BUSINE$S~ !PERSONAL PROPERTY 'AND • PERSONAL PROPERTY OF OTHERS 3. INCOME ~PROTECT~ION ~ OCCURRENCE • •UF2860 03/09 * IMPORTANT NOTICE - ULTRAFLEX PACKAGE. • FORMS REVISION - SUMMARY OF CHANGES IL0910 07/.02 PENNSYLVANIA NOTICE IL0246 09/07 PENNSYLVANIA CHANGES - CANCELLATION AND NONRENEWAL GU44 03/01 PENNSYLVANIA AMENDATORY ENDORSEMENT IL0985~* ~ 01%08; DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT . UF87.05* 06/96: IMPORTANT NOTICE - NO FLOOD COVERAGE UF4.810 03/08 IMPORTANT~NOTICE POLICY SERVICE .FEES UF6330* 0.1/O1 * IMPORTANT NOTICE: DO YOU•TJSE~SUBCONTRACTORS? FX0001 01/05 ULTRAFLEX COMMERCIAL PROPERTY COVERAGE PART GU110 05/06 ULTRAFLEX COMMERCIAL~PROPERTY • COVERAGE PART AMENDATORY ENDORSEMENT GU51 03./01 PENNSYLVANIA AMENDATORY~ENDORSEMENT. IL0952~ ~ '01'/•08 ~ CAP~'ON L05$ES:.FROM ~CERTIFIED• ACTS OF TERRORISM ' UF4110 01/08 IMPORTANT NOTICE TO POLICYHOLDERS -~ TERRORISM COVERAGE - PROPERTY C(~0435 10/O1 EMPLOYEE BENEFITS LIABILITY ,COVERAGE ULLK 12/07 WHOLESALERS ERIEPLACEABLE ENHANCEMENTS ENDORSEMENT DJ2 05/28/09 1 i. t SCHEDULE OF FORMS (CONTINUED) '.s FORM NUMBER EDITION DATE ,.DESCRIPTION ULRH 09/05 ADDITIONAL INSURED - OWNERS, LESSEES,, OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED' IN CONSTRUCTION AGREEMENT WITH YOU ULOY 03/01 COVERAGE FOR PUNITIVE DAMAGES CG0001 12/07 * COMMERCIAL GENERAL LIABILITY COVERAGE FORM '. •ULED 0,9%05 EXCLUSION - ASBESTOS FX0003 01/.05 ULTRAFLEK EXTRA LIABILITY COVERAGES ULQN 04/06 EXCLUSION - PROFESSIONAL LIABILITY CG0099 11/85 CHANGES IN GENERAL LIABILITY FORMS FOR COMMERCIAL PACKAGE POLICIES• CG2147 12/0:7 * EMPI;OYMENT-RELATED PRACTICES EXCLUSION IL0021 09/08 *~ NUCLE~~R ENERGY LIABILITY EXCLUSION ENDORSEMENT GU30 03/01 AMENDMENT OF POLICY - TWO.OR.MORE.COVERAGE PARTS GU32 03/01 EXCLUSION - LEAD LIABILITY' IL0017 11/•98 * COMMON POLICY CONDITIONS CG2167 12/04 * FUNGI OR BACTERIA EXCLUSION CG0062 12/02 WAR LIABILITY EXCLUSION CG2170 0.1/Q$ CAP ON LOSSFsS FROM CERTIFIED•ACTS OF TERRORISM UF4111 01/08 IMPORTANT NOTICE TO POLICYHOLDERS - • TERRORISM•COVERAGE.- LIABILITY UF8385 03/95 * IMPORTANT~NOTICE 98 CONTINUED ON NEXT PAGE ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY RENEWAL CERTIFICATE AA7489 THE HESS AGENCY 08/01/09 TO 0~8/O1/TO Q44 0151498 H HAMMER EXPRESS.INC PO BOX 60709 . HARRISBURG PA 1'7106-0709 SCHEDULE OF FORMS (CONTINUED). FORM NUMBER• EDITION DATE DE$CR~I•PTI~N CG2196 03/05 * SI•LICA•OR SILICA-RELATED DUST,EXCLUSION~ GU136 03/09 * AMENDMENT OF MOB3LE EQUIPMENT DEFINITION CG2229 11/85 EXCLUSION - PROPERTY ENTRUSTED DJ2 05/28/09 i AGENTS•RATING WORKSHEET ERIE INSURANCE EXCHANGE • ULTRAFLEX POLICY RENEWAL CERTIFICATE AA7489 THE HESS AGENCY 08/01/09 TO 08/01/10 Q44 0151496 H• HAMMER EXPRESS INC PO' BOX 60709 HARRISBURG PA 17106-0709 • AGENT'S RATING~WORKSHEET' I;OC 1, BLDG 1 DEDUCTIBLE ~ 500 ST_PA COUNTY 205 PROT 04 CONNT 31 ~ CLASS 000963 ., RATE CLAS • BUILDING ST YR CON 0000 AGR}'sED AMT R/O L/R ~ :APT~'CR CSP •0000 PERILS' COINS 0 ~REL FACT 0..000 ~ ~ , GRPl RT 0.0.00 GRP2 RT '0.000. BLANKET RT F/•V~ WH •AGE 00' LD 00. BLDG.AMT, 0 F/RATE 0.000 PREM MOD~0.0.00 BLDG PREM 0 .. • ..CONTENTS . . ST PA, AGREED AMT-N~ COV SYM Y APT CR N CSP 1212 PERILS A COINS 80. REL.FACT 1.000 GRP1 RT 0.248 GRP2 RT 0.070 BLANKET RT N WH N LD 10 CONT AMT 25000 F/RATE 0:311 PREM MOD 1.000 CONT PREM 78 LIABILITY PROTECTION. LIMIT,.1000/2000 TYPE DUAL PREM MOD 1.000 DL •DED••'- 0.~ LD •10, _EXP RAT_ING• 001:00.0 YR• CON 0000 R 'LI•AB R .. ~ ACTUAL . ~~MIN $Q • ST CTY 'T '17L liE TRH , ~CI;AS H~ EXPOSURE RATE DED ~ PREM ' PREM '.01 PA 205 ~S• N N 19 000963 P • 3.80000 17.630 ~ 66'99 198 THEFT ~ ~.. ST~PA CTY 205' CODE.•2~•~DED~ 500 PREM MOD 1.000 AMT 2500.0 PREMIUM 41 LOC 2, BLDG 1 LIABILITY PROTECTION LIMIT 1000/2000 TYPE DUAL PREM MOD 1.000 DL DED 0 LD 10 EXP RATING 001.000 YR CON 0000 R LIAB R ACTUAL MIN SQ ST CTY T DL LE TR CLAS B EXPOSURE RATE DED PREM PREM O1 PA 205 S N N 19 000963 P 1 1'7.630 0 198 ADDITIONAL PROPERTY COVERAGES PREMIUM 99 DJ2 05/28/09. RTT REVISED DECLARATIONS AA7489 THE HESS .AGENCY HAMMER EXPRESS INC~ PO• BOX 60709 , HARRISBURG PA 17106-0709 a 08/01/09 TO 08/01/10 Q44 0151498 H • • POLICY PERIOD BEGINS AND ENDS AT 12.01 A.M. STANDARD'TIME AT THE STATED ADDRESS OF THE NAMED INSURED. THE INSURANCE APPLIES TO THOSE PREMISES DESCRIBED AS PER THE ATTACHED SUPPLEMENTAL DEs'CLARATIONS. THIS IS SUBJECT TO ALL APPLICABLE TERMS OF THE. POLICY AND. ATTACHED FORMS AND ENDORSEMENTS DEDUCTIBLE (PROPERTY PROTECTION ONLY)-•$ 500. COVERAGES : • ". DEPOSIT PROPERTY PROTECTION -,AS PER THE ATTACHED SUPPLEMENTAL•DECLAR.ATIONS' PREMIUM 1. BUILDINGS - ~ ~ $. .2. BUSINESS PERSONAL PROPERTY AND PERSONAL~•PROPERTY OF•OTHERS ~ $ INCL 3. INCOME PROTECTION •• ~ $ 4. GLASS AND LETTERING .:_ $ 5. SIGNS, LIGHTS AND CLOCKS ~ $ • LIMITS OF INSURANCE ~PREMIUM• BASIS _ PAYROLL EACH OCCURRENCE.~LIMIT 000 $ 1,000,. • . DAMAGE• TO PREMISES• $~ INCL RENTED~TO YOU LIMIT $ 1,000,000 ANY ONE PREMISES MEDICAL EXPENSE'LIMIT $ 5,000 ANY ONE PERSON PERSONAL & ADVERTISING INJURY LIMIT $ 1,000,000 ANY ONE PERSON OR ORGANIZATION GENERAL•AGGREGATE LIMIT $ 2,000,000 PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $ 2,000•,000 . OPTIONAL .COVERAGES. EMPLOYEE; BENEFIT LIABILITY - $1000•DEDUCTIBLE $ 1,,000.,:0.00."EACH EMPLOYEE ~ , .:$ 2•,;0;00,•000 AGGREGATE RETROACTIVE ;DATE •08/O1/•Z 999 • ENHANCEMENT ENDORSEMENT - WHOLESALERS.•ENDORSEMENT~ ADDITIONAL INSURED.- OWNERS,. LES$EES'OR.CONTRACTORS ' •• TOTAL 'DEPOS•IT~ PREMIUM APPLICABLE FORMS - SEE SCHEDULE OF FORMS "~• ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY (ULRH), $ INCL $. INCL $ INCL $ 4,699. HJZ 07/08/09 SUPPLEMENTAL DBCLARATIONS LOCATION 1, BUILDING 1 LOCATION OF•PREMISES OCCUPANCY/OPERATIONS 3500, INDUSTRIAL RD; HARR~I•SBURG, COMMERCIAL; WAREHOUSE-•INCLUDING • DAUPHIN CO. PA 17103 OFFICE (RFD: HARRISBURG) INTEREST OF NAMED INSURED IN SUCH PREMISES;-,TENANT PROPERTY PROTECTION. ~ , COVERAGES CO-INS ~ AMOUNT OF INSURANCE 1.. BUILDINGS ~ ~ • :• 2. BUSINESS' PERSONAL •PROPERTY AND 80; $ 25, 00.0 ' PERSONAL PRQPERT7l OF• OTHERS 3. INCOME PROTECTION OCCURRENCE OPTIONAL COVERAGES = PROPERTY PROTECTION LOSS PAYEE •~ •SOVEREIGN BANK ~ .. . • ~ ~ATTN::'MAIL ~CODE~• 60-571-CM1 '6 T9 ALEXANDER' RD'~ ~ ~ • • PRINCETON NJ 08540-6000 98 CONTINUED ON NEXT PAGE ERIE-INSURANCE EXCHANGE ULTRAFLEX POLICY - REVISED DECLARATIONS AA7489 THE .HESS AGENCY 08/01/09 TO 08~/.OT/1~0. .Q44 0151498 H HAMMER EXPRESS INC PO BOX 60709 - HARRISBURG PA .17106-0709 SUPPLEMENTAL DECLARATIONS LOCATION 2,. BUILDING 1 LOCATION OF PREMISES OCCUPANCY/OPERATIONS. .3900 INDUSTRIAL RD, HARRISBURG, WAREHOUSE - CGL-COVERAGE PART ONLY DAUPHIN CO, PA ~17;;103• ,' ~ .. - ~(RFD: HARRISBURG) INTEREST OF~~NAMED'INSURED.iN SUCH PREMISES - TENANT ' PROPERTY PROTECTION COVERAGES CO-INS ~ 1. BUILDINGS 2. BUSINESS PERSONAL PROPERTY AND PERSONAL; PROPERTY OF OTHERS 3. INCOME PROTECTION OCCURRENCE AMOUNT OF INSURANCE HJZ 07/08/09 - SCHEDULE`OF FORMS ~' FORM,NUMBER~ EDITION DATE DESCRIPTION ULF 03/01 ULTRAFLEX PACKAGE•POLICY UF6330* O1/O1 * IMPORTANT NOTICE: DO YOU USE SUBCONTRACTORS? UF2860 03/09 * IMPORTANT NOTICE - ULTRAFLEX PACKAGE • FORMS REVISION - SUMMARY OF CHANGES IL0910 07/02 'PENNSYLVANIA NOTICE I•L'0246 09/0.7' PENNSYLVANIA CHANGES - CAIJCELLATION . AND NONRENEWAL • :GU44 03/,01 ~ , PENNSYLVANIA AMENDATORY ENDORSEMENT a IL0985* O1/OS' DISCLOSURE PURSUANT. TO TERROR3SM RISK INSURANCE ACT. UF8705* 06/96 IMPORTANT NOTICE - NO FLOOD COVERAGE UF4810 03/0$ IMPORTANT NOTICE - POLICY SERVICE FEES FX0001 01/05 ULTRAFLEX COMMERCIAL PROPERTY COVERAGE PART GU110 05/06 ULTRAFLEX COMMERCIAL PROPERTY COVERAGE PART AMENDATORY ENDORSEMENT GU51 IL0952 UF4110 CG0435 ULLK 9 8' 03/01 PENNSYLVANIA AMENDATORY ENDORSEMENT 01/08 CAP ON LOSSES FROM CERTI•F'I•ED ACTS OF TERRORISM 01/08' IMPORTANT NOTICE~TO POLICYHOLDERS - TERRORISM COVERAGE - PROPERTY 10/O1 EMPLOYEE BENEFITS~LIABILITY COVERAGE 12/07 FTHOLESALERS ERIEPLACEABLE ENHANCEMENTS ENDORSEMENT CONTINUED ON NBXT PAGE • REVISED DECLARATIONS AA74 8 9 , 'THE HESS AGENCY, HAMMER EXPRESS• ,INC PO 'BOX 60709 HARRISBURG PA•. 171 U.6-0?09 ' .. ERIE INSURANCE EXCHANGE ULTRAFLEX.POLICY 08/01/09 TO 08/01/10 Q44 0151498 H SCHEDULE OF FORMS (CONTINUED) ' 'FORM NUMBER EDITION DATE DESCRIPTION ULRH 09/05 ADDITIONAL INSURED - OWNERS, LESSEES, OR ' CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN~CONSTRUCTION AGREEMENT WITH YOU ULOY 03/01 COVERAGE FOR PUNI'T'IVE DAMAGES' CG0001 '12/07 * COMMERCIAL GENERAL LIABILITY COVERAGE FORM ULED 09'/•05 EXCLUSION :ASBESTOS' . FX0003 01/05 ~ ULTRAFLEX EXTRA LIABILITY COVERAGES ,• ULAN ~ • 04/:06 EXCLUSION -'PROFESSIONAL LIABILITY r . CG0099 ~ 11/'85 CHANGES IN. GENERAL LIABILITY FORMS•FOR COMMERCIAL • ~ PACKAGE POLICIES ~ " CG2147 12/07. * EMPLOYMENT-RELATED'PRACTICES EXCLUSION ' IL0021 09/08 * NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT GU30 03/01 AMENDMENT OF POLICY -'TWO OR MORE COVERAGE PARTS GU32 03~/O1 EXCLUSIOIJ~ - LEAD LIABILITY .IL0017' 11/98 * COMMON!P.OLICY CONDITIONS •.CG21;67 ~ 1.2-/04 * FUNGT. OR .BACTERIA EXCLUSION . CG0062 12/02 WAR LIABILITY ~EXCI;USION •• ~ ' CG2170 01/08 CAP ON LOSSES FROM CERTIFIED. ACTS'OF'TERRORISM UF4111 01/0'8 .IMPORTANT :NOTICE TO POLICYHOLDERS'- TERRORISM COVERAGE - LIABILITY UF8385 03%95 * IMPORTANT NOTICE • ,. ~~ ~ HJZ ..07./08/09 ~ _ r . . ~ ~ SCHEDULE OF FORMS (CONTINUED) FORM. NUMBER EDITION DATE .DESCRIPTION CG2196 03/05 * SILICA OR SILICA-RELATED DUST EXCLUSION , GU136 03/09 * AMENDMENT OF MOBIL'E~EQUIPMENT DEFINITION CG2229 11/85 EXCLUSION - PROPERTY ENTRUSTED 98 REVISED DECLARATIONS i ., I AGENTS RATING WORKSHEET ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY ;, ~i AA7489 THE HESS AGENCY 08/01/09 TO 08/01/10 Q44 0151498 H HAMMER EXPRESS. INC~ • PO BOX 60709 ' HARRISBURG PA 17106-0709 AGENT'S RATING WORKSHEET LOC 1,•BLDG 1 DEDUCTIBLE 500 - ST PA COUNTY 205 PROT 04 CONST 3.1 CLASS•.000963 RATE CLAS - BUILDING • •ST YR CON' 0000 AGREED AMT R~/O L/R-. APT CR CSP 0000 PERILS COINS 0 REL FACT 0.00.0 - GRP1 RT 0.000- GRP2 RT 0.000• BLANKET RT F/V WH AGE 00 LD'00 .BLDG AMT 0 F/RATE '0.000- PREM MOD 0:000 BLDG PREM CONTENTS ST PA AGREED.AMT N COV SYM Y APT CR N :CSP 1212 PERILS A COINS 8'0 REL FACT 1.000 GRP1 RT 0.24`8 •GRP2 RT 0.070 BLANKET ~RT N WH N LD 10 - CONT AMT 25000 F/RATE 0.-311 PREM MOD 1.:000 CONT PREM LIABILITY PROTECTION LIMIT 1000/20,00 TYPE DUAL PREM MOD 1..000 DL DED 0 LD 10 EXP RATING 001.000 -YR CON 0000 R LIAB . R- - ACTUAL MIN SQ ST CTY T DL ~ ' LE TR CLAS~ B ~ •EXPOSURE: RATE DED PREM' PREM O1 PA .205' S N N 19 000963 P 22500,0 17:630' 3967 1'98. THEFT ~ _ ST•PA CTY 205 CODE 2 DED 500 PREM MOD 1.000 AMT 25000 PREMIUM ~LOC ~ 2 , BLDG ~ 1: ~ ~ - LIABI-CITY PROTECTION LIMIT 1000/2000° TYPE DUAL PREM MOD 1.000 DL DED 0' ~L,D• 10 EXP RATING 001.000 YR CON 0000 • R ` LIAB R ACTUAL MIN, SQ:ST CTY T DL LE TR ~CLAS B EXPOSURE RATE DED .PREM PREM 07. PA 205 S N N 19 000963. P 1 17•.630 0 1'98 0 78 41 CONTINUED ON NEXT PAGE HJZ 07/08/09 ERIE• I1+iSURANCE EXCHANGE ULTRAFLEX POLICY " REVISED DECLARATIONS AA7489 THE HESS AGENCY •HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA 17106-0709 ~~. 08/01/09 TO 08/01/10 Q44 01:51498 H • AGENT' S• RATING WORKSHEET ADDITIONAL•INSURED:ENDORSEMENT COVERAGES ST PA `TOTAL LI•AB~ PROTECTION PREMIUM $. - 396'7 • ACTUAL ~ ADJ . PREM ~ ~ PREM. •_ OPERATIONS - BLANKET (UL-RH) ,$ 67 $ 67 TOTAL PREM ~ •$ EMPLOYEE BENEFIT LIABILITY COVERAGE _ • $T; PA. NO' OF EMP 11. .LIMIT 1000 RATE 0.000 PREMIUM. . RETROACTIVE •DATE• 08/01•/1999• - ENHANCEMENT ENDORSEMENTS ST CTY •CLASS PREMIUM WHOLESALERS ENDORSEMENT PA 205 000963 150 ADDITIONAL PROPERTY COVERAGES PREMIUM ' ~ - '~ 67 297 99 xJZ o~/os/o9 i RTT ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY AMENDED DECLARATIONS * * EFFECTIVE 08/01/09 ATTACH THIS TO YOUR POLICY. REASON FOR AMENDMENT SEE'*** ON FIRST DECLARATIONS PAGE AA7489 THE HESS AGENCY 08/01/09 TO 08/01/10 Q44 0151498 .H HAMMER EXPRESS INC , PO BOX 60709 HARRISBURG PA 17106-0709 * * * * * NOTICE 'OF AMENDMENT * * KEEP THIS COPY AND ATTACH IT TO YOUR POLICY ***UNDER LIABILITY PROTECTION, AMENDED PAYROLL FOR CODE 0963 WAREHOUSE TO $125,000: . PREMIUM REDUCTION DUE'TO.THIS CHANGE - - - •- - - ~- , ~ ~ ~- ~ i -{ ~ i i $ 1.,'7.93C KEM 08/31/09 ~- - ~. . AGENTS .RATING WORKSHEET ~~ ERIE INSURANCE EXCHANGE ULTRAFLEX•POLICY AMENDED DECLARATIONS * * EFFECTIVE 08/01/09 ATTACH THIS TO YOUR POLICY. REASON FOR AMENDMENT SEE *** ON FIRST DECLARATIONS PAGE AA7489 THE HESS AGENCY 08/01/09 TO 08/01/10 Q44 0151498 H HAbII~lER EXPRESS I~NC PO' BOX 60.709 HARRISBURG PA17106-07U9 AGENT'S •RATING• WORKSHEET LIABILITY PROTECTION LIMIT 1000/2000 TYPE DUAL PREM MOD 1.000 DL DED 0 LD 10 ~ ~ EXP.' RATING 001.•000 •, YR' CON .0000 R LIAB R ~. ACTUAL MIN SQ ST CTY T DL LE TR CLAS B EXPOSURE RATE DED PREM PREM O1 PA 205 S N N 19 000963 P 125000 17.630 2204 198 ADDITIONAL INSURED ENDORSEMENT COVERAGES ST PA TOTAL••LIAB~~PROTECTION PREMIUM $ 2204 ACTUAL 'ADJ . ~ PREM PREM OPERATIONS - BLANKET (UL=RH).~ ~ $ 37 $. ~ 37 . ~ TOTAL PREM ~ $ _, 37 ,, KEM 08/31/09 RTT ERIE INSURANCE EXCHANGE ULTRAFLEX POLICY - ~• AMENDED DECLARATIONS * * EFFECTIVE 08/01/09 ATTACH THIS TO YOUR POLICY.. REASON FOR AMENDMENT SEE *** ON•FIRST DECLARATIONS PAGE •AA7489 THE HESS AGENCY 08/01/09 TO QS/O1/10 Q44 0151498 H HAMMER•EXPRESS INC • PO BOX 60.7 0 9 • HARRISBURG PA 17.106-0709 * * * * * NOTICE OF AMENDMENT * *,* KEEP THIS COPY AND ATTACH IT TO YOUR POLICY ***UNDER LIABILITY PROTECTION, AMENDED PAYROLL FOR CODE 0963 WAREHOUSE TO•$ 25,000. PREMIUM REDUCTION DUE T0. THIS CHANGE.- - - - - - $ 1,770C CPMLM 10/28/09 i ,~ ;•~. .. AGENTS: RATING WORKSHEET ERIE~INSURANCE EXCHANGE • ULTRAFLEX :POLICY AMENDED DECLARATIONS * * EFFECTIVE 08/01/.0,9 ATTACH~THIS TO YOUR POLICY. REASON~FOR AMENDMENT SEE *** ON FIRST DECLARATIONS PAGE AA7489. •THE HESS AGENCY HAMMER EXPRESS' ~INC PO 'BOX 60709 ' HARRISBURG PA 17106-0709 ' AGENT'S RATING WORKSHEET .• • LIABILITY PROTECTION LIMIT 1000/2000 'TYPE DUAL PREM 'MOD'' 1.:000, DL DED, 0; 'LD TO EXP RATING ~ 001.000 •YR~ CON' 0000. R•• LIAB R ~ ACTUAL MIN SQ ST CTY T DL LE TR CLAS B EXPOSURE RATE DED ••PREM PREM 'O1 PA 205. S N~ N 19 000963 P -25000 17.630 441. 198 ADDITIONAL INSURED ENDORSEMENT COVERAGES ST PA • 'TOTAL•LIAB PROTECTION PREMIUM $• 44,1 ACTUAL ADJ • PREM ~ PRfiM OPERATIONS _ BLANKET (UL - RFi) ' $ 7 •, $ ' • • 3 0 •. TOTAL PREM, $ 08/01/09 T0,08/O1/10 Q44 0151498 H 30 ~. CPMLM 10/28/09 r=:~~ ~~=.:~~_ - = =.~ ~ ~ : A000UNT~SUMMARY°; . _ - - _ - _- __ _ { _::_ -j.. _~~... - - ERIE INSURANCE GROUP Insured and Account Number. HAMMER EXPRESS INC Q44 0151498 A ant Number. AA7489 T of Pol ULTRAFLEX.PACKAGEPOL1CY Date of Summa 7!19!201011:58 Date Transaction. Charges ~ Credits Notes 5 8h/2009 2009 renewal $7;478.00 6 8/1/2009 endorsment. ~ -$2;779.00 $7,478.00 - $2,779.00 = $,4;1399.00 7 8/1/2009 endorsment -$1.793.00 8/1/2009 late fee •$10.00 8 8!112009 endorsment -$1;770.00 8h/2009 service cha ~ ~$i0:00 8/1/2009 Iate.fee $10.00 8/1/2009 service die $5:00 3/26/2010 cancelled -$399.00 12!1412009 ~ ment -$91.00 1 h 7/2010 payment -$91.00 2!1812010 ment -$151.00 11/18/2009 balance forward $292.00 rior ear Subtotals $7;805.00 =$7,074.00 Total Earned Premium $731.00 Earned remium owed on this poll EXHIBIT a JJy Q --~ ~:.~:.:~• - _ _- T~-==~-~ -1'• _ _ AC.C;O,UNT:rtSUMMARY~x~ ~:;.- ~~-~-~ ...~-.=_,,.~;.k-; r :~.~a~: .cur..--F,.~~..n,-.__-.}......rr++.::.-w..`..-~i:=.:..:.,ir :~~w..+,V'.anrtw T.r~f:. ERIE~INSURANCE t3ROUP Ensured and Account Number: HAMMER`F~CPRESS INC X44 0151498 ent Number: AA7489 T ;af Poi ULTRAFLEX PACKAGE POLICY Date of Summa 7h91201011:58 ' Date Transacdon• Charges. Credits Notes 1 8/1/2008 2008:renewai $9,425:00 2 6/1/2008 endorsment -$122.00 $9,425.00 - $122:00 = $9,303:00 811~OOB service cha a $5.00 - 3 8/1lZ006 endorsment -$2,821.00 811/2008 late~fee $10.00 4 Bh12008 2006?audit $465.00 rocessed 11!17!09 9117!2008• a - ent -~2•~ 10/30/2008 a ent -$377.00 1112!2009 a meet -$188:00 415J2009 a' ent -$258.00 5/11/2009 pa ent -$ro7.oo 5128!2008 balance forward -$4,858:00 or year Subtotals $9,925.00 =$9;833.00 Total Eamed Premium $292.00 Earned premium carried over to the followin ear RTT RENEWAL CERTIFICATE AA7489 THE HESS.AGENCY HAMMER EXPRESS INC PO BOX 60709 HARRISBURG PA 17106-0709 ' ERIE INSURANCE EXCHANGE BUSINESS CATASTROPHE POLICY 08/01/09 TO OS/.O1/10 Q32 0171087 H POLICY PERIOD 'BEGINS•AND ENDS AT 12:01 A.M., STANDARD TIME AT THE ADDRESS OF THE NAMED INSUR1sD : ' LEGAL ENTITY - CORPORATION DESCRIPTION OF OPERATIONS COMMERCIAL WAREHOUSING CLASS CODE - 049763 THE ERIE'S LIMIT FOR THIS COVERAGE TO THE•TERMS OF THE POLICY AND ITS ---------------------------------- COVERAGE AND LIMITS - BUS; LIMIT OF .LIABILITY AGGREGATE LIMIT IS SHOWN BEIAW. THIS•INSURANCE IS SUBJECT FORMS. • INESS CATASTROPHE•LIABILITY•COVERAGE $ 10,000,000 EACH OCCURRENCE $ 10,000,000 WHERE APPLICABLE CBJ ~ - TOTAL• PREMIUM. - - - - - - - -, - .- - $ 4683. .•APPLICABLE FORMS _ SEE SCHEDULE OF FORMS, J Q y J EXHIBIT 07/01/09 SCHEDULE OF UNDERLYING INSURANCE TYPE OR DESCRIPTION: ULTRAFLEX :INSURER: E ;I E POLICY NUMBER: Q44 0151498. POLICY PERIOD: 0~8-01-09/10 LIMITS OF INSURANCE: . • EACH OCCURRENCE LIMIT $ 1,000,000 PERSONAL &: ADV.ERTISING~ INJURY LIMIT $ 1, 000,'000 GENERAL AGGREGATE ~ $ 2,000,000 PRODUCTS/COMPLETED. OPERATIONS AGGREGATE LIMIT $ 2,000,000 TYPE OR DESCRIPTION: EMPLOYERS LIABILITY INSURER: E I C. POLICY NUMBER: Q92 5100132' POLICY PERIOD: 08-0.1-09/10 LIMITS OF INSURANCE: BODILY INJURY, 'BY ACCIDENT $ 100,0.00 EACH ACCIDENT . BODILY INJURY. •BY~ DISEASE $ 500; 0.00 ,POLICY LIMIT' _ ~BODI~LY INJURY•,BY DISEASE $ 100,000 EACH EMPLOYEE TYPE OR•DESCRIPTION: COMMERCIAL AUTO INSURER: E I E POLICY NUMBER: Q11 0130730 .POLICY PERIOD: 11-O1-08/09 •LIMITS OF INSURANCE: ~, BODILY INJURY AND PROPERTY DAMAGE PER ACCIDENT $ T,000,000 Q32,0171087 CONTINUED. ON NEXT PAGE . ERIE. INSURANCE EXCHANGE . BUSINESS CATASTROPHE•POLICY RENEWAL CERTIFICATE ' AA7489 THE HESS AGENCY 08/01/09 TO 08/01/10 Q32 017108'1 H HAMMER EXPRESS •INC ' PO .BOX 60709 • . ~ ~ • HARRISBURG PA 17106-0709 • SCHEDULE .OF UNDERLYING INSURANCE CONTINUED' - • .:'TYPE OR DESCRIPTION:: SPECIAL COVERAGB ENDORSEMENT-EMPLOYEE~BENEFIZ' LIABILITY INSURER•:~ E I E • ~ • POLICY NUMBER: Q44 015.1498 POLICY PERIOD: 08=01-09/10 LIMITS OF INSURANCE: EACH~EMPLOYEE LIMIT $ 1,000,000 ,AGGREGATE LIMIT $ 2,000.;000 _ ' MISCELLANEOUS ENDORSEMENT SCHEDULE CAT-100 EXCLUSION OF VEHICLE LIABILITY• ALL VEHICLES EXCE;UDED. FROM COVERAGE UNDER ~POI;ICY Q11 01307.30 07/01/09 Q32 0171087 CONTINUED ON NEXT PAGE ERIE •INSURANCE• EXCHANGE• BUSINESS CATASTROPHE POLICY , RENEWAL CERTIFICATE AA7489 'THE HESS AGENCY HAMMER•EXPRESS INC • PO. BOX 60709 HARRISBURG PA 17106-07.09 • FORM NUMBER BCL CU.O.131 I~L0910 CAT156 CAT160 .CAT165 CAT166 EDITION DATE' 04/03 09/00 • 07%•0.2 04/03 • . . 04/03 ~ .04/03 0 4'/ 0 3 OB/01~/09 TO '08/01/10 Q32 0171087 ••H SCHEDULE OF FORMS • DESCRIPTION BUSINESS CATASTROPHE•LIABILITY POLICY PENNSYI;VANI•A CHANGES PENNSYLVAN•I•A NOTICE COVERAGE FOR PUNI~T•I~VE 'DAMAGES WORKERS COMPENSATION~EXCLUSION EXCLUDING•COVERAGE ENDORSEMENT BUSINESS CATASTROPHE LIABILITY EXTRA COVERAGES 1 - - _~ UF4810 CU2130 UF4'0 8 3 IL0985* CAT1~0.0 CU0001 UF2863 GiJ143 IL0246 CU2700 CLJ04 0 3 ,. , 03/08 IMPORTANT NOTICE-POLICY SERVICE FEES O1/OS CAP ON LOSSES FROM .CERTIFIED ACTS OF TERRORISM 01/08 IMPORTANT NOTICE TO POLICYHOLDERS = TERRORISM COVERAGE - BUSINESS CATASTROPHE LIABILITY O1/OB DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT - 04/03 EXCLUSION•OF VEHICLE LI~AB~ILITY 12/07 * COMMERCIAL LIABILITY UMBRELLA COVERAGE FORM •03/09 ~* IMPORTANT NOTICE -BUSINESS CATASTROPHE LIABILITY FORMS•REVISION-SUMMARY OF CHANGES 03/09 * AMENDMENT OF MOBILE EQUIPMENT DEFINITION 09/.Q7 * PENNSYLVANIA CHANGES - CANCELLATION AND•NONRENEWAL 12/04 * UNDERLYING :CLAIMS-MADE COVERAGE 12-/,07 * EMPLOYEE BENEFITS LIABILITY COVERAGE • 07/01/09 '- ~~- - - -- is ~=:~ ..~_.-~ -_- ___,_ ACCOUNT. SUMMARY:<~ ~:':=:~ w~.r_ . ,. _ - ,...___ _`-~~.::~°. ERIE INSURANCE GROUP Inaureii antl Account Number: HAMMER EXPRESS:INC Q32 0171087 A ent'Number: AA7489 T of Polic : BUSINESS CATASTROPHE POLICY Date of,3umma 71191201011:54 Date Transaction Charges Credits ~ Notes; 4 8/1/2009 2009 renewal $4;883:00 8H12009 service cha a 515:00 8!1/2009 late fee $10:00 8!112009 service char a $10:00 • 12/29/2009 cancelled -$2;757:00 12H412009 t ' -$250.00 2/18/2010 a menu =$84.00 1H812010 p~-ment -$249.00 7/2/2009 credit brought -$762.00 rior~r fonaard ~- ~ . f Subtotals j $4,718:00 -$4;102.00 ~_ - Total Earned Premium .$616.00 Earned premium owed on this policy EXHIBIT 0 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW ERIE INSURANCE EXCHANGE iff N Pl i ~G ~ 7 ~~ ~ l: ~ U~ I o. a nt vs. c Q ~'' `~°~ HAMMER EXPRESS, INC. ~'n°Di r°~ r~*t ~.~ CIVIL ACTION ~~' ~ o° Defendant ~~ ..~ arc ~ Z ~ ~. c tv °r~ ENTRY OF APPEARANCE ~ ,~,~, ~, _.~ Kindly enter my appearance on behalf of Plaintiff, ERIE INSURANCE EX CHANGE, in the above-captioned matter. AMATO AND LESSA, P.C. By: 1.. ~-~ Ronald Amato, Esq., Atty ID #32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor Erie Insurance Exchange vs. Hammer Express, Inc. -FFICE F TNELPR T 4 HOIJC i p-y ?010 DEC 20 PM 2: 58 'IMBBRLAND CoLiN ?. ` ENNSYLVAfllA Case Number 2010-7421 SHERIFF'S RETURN OF SERVICE 12/16/2010 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states that he made a diligent search and inquiry for the within named defendant to wit: Hammer Express, Inc., but was unable to locate them in his bailiwick. He therefore returns the within Complaint and Notice as not found as to the defendant Hammer Express, Inc. Deputies were advised, Hammer Express, Inc. is no longer in business, Earl McClearry was the owner of Hammer Express, Inc., but he does not reside at 5845 Aspen Lane, Enola, Pennsylvania 17025. Earl McClearry's current whereabouts are unknown. SHERIFF COST: $60.00 December 16, 2010 SO ANSWERS, i RONW R ANDERSON, SHERIFF COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA C) CIVIL ACTION - LAW n G ; -- - s ERIE INSURANCE EXCHANGE w rw C) o Plaintiff No. 10-7421 Civil -v vs. : _ y HAMMER EXPRESS, INC. CIVIL ACTION Defendant(s) PRAECIPE TO REINSTATE COMPLAINT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Please reinstate the complaint in the above-captioned case. AMATO ARM' By: Ronald Amato-EsgVAtty #DI 32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID 984464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM ? ?l0• UL codel s 0 asst s-o? SHERIFF'S OFFICE OF CUMBERLANDF??#Ty`:-- Ronny RAnderson T}^ Sheriff ??yy Jody S Smith 20,311 FEB 14 AM 10- Chief Deputy Richard W Stewart Solicitor Amended' Erie Insurance Exchange Case Number vs. Hammer Express, Inc. 2010-7421 SHERIFF'S RETURN OF SERVICE 02/10/2011 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states that he made a diligent search and inquiry for the within named defendant to wit: Hammer Express, Inc., but was unable to locate them in his bailiwick. He therefore returns the within Complaint and Notice as not found as to the defendant Hammer Express, Inc. Request for service at 804 Kent Drive, #20, Mechanicsburg, Pennsylvania 17050 is Earl McCleerey's (Officer of Hammer Express, Inc.) brother's residence. 02/11/2011 Jason Vioral, Sergeant, who being duly sworn according to law, states that on February 11, 2011 at 1545 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Hammer Express, Inc., by making known unto Darrell Ballard, President of Hammer Express, Inc. at The Cumberland County Sheriffs Office, 1 Courthouse Square, Room 303, Carlisle, Cumberland County, Pennsylvania 17013 its contents and at the same time handing to him personally the said true and correct copy of the same. Darrell Ballard currently resides at 100 Casey Meadow Place, Sandston, Virginia 23150. JASON L, DEPUTY SHERIFF COST: $42.00 February 10, 2011 RON ~ R ANDERSON, SHERIFF Acceptance of Service I accept the service of the complaint and Notice (on behalf of Earl Mccleerey and certify that I am authorized to do so.) February 11, 2011 Date 4uthorized Agent /00 CXSrc y 141?4,4)61G PZ- Sktv Ps -to,lj vA a 3 /S70 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ERIE INSURANCE EXCHANGE Plaintiff No. 10-7421 Civil vs. HAMMER EXPRESS, INC. CIVIL ACTION .- , - U" rn M Defendant N) ca ` s PRAECIPE FOR JUDGMENT C:) a C) D D E5 -r Cl S r i c.0 TO THE PROTHONOTARY, CUMBERLAND COUNTY: co 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 $17,030.38 Interest (from November 29, 2010 to March 16, 2011 at 6% per annum) 255.45 Payments Total $17,285.83 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, 1 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 March 4, 201 1 . Dated: March 16, 2011 2093308 AMATO LESSA, P.C. By: Ronald Amato, Esq., Atty I 2323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM Qt} X14.00 to Mki ckIV agT oO7 vz*;s14 91(V t?DfiYr fvw Ied • IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ERIE INSURANCE EXCHANGE Plaintiff vs. HAMMER EXPRESS, INC. Defendant No. 10-7421 Civil CIVIL ACTION CERTIFICATION OF ADDRESSES I do certify that the precise last known address of the within named plaintiff is: 100 Erie Insurance Place Erie PA 16530 I do certify that the precise last known address of the within named defendant is: 100 Casey Meadow Place Sandston VA 23150 AMA D P.C. By: Ronald Amato, Esq., Atty ID #32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ERIE INSURANCE EXCHANGE Plaintiff : No. 10-7421 Civil vs. HAMMER EXPRESS, INC. Defendant(s) TO: Hammer Express, Inc. 100 Casey Meadow Place Sandston VA 23150 Date of Notice: March 4, 2011 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 WITHOUT A 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 AMATO AND LES P. By: Ronald Amato, Esq., Atty ID #32323 Michael R. Lessa, Esq., Atty ID #88617 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM Attorney File# 2093308