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BUSINESS AUTO DECLARATIONS <br />Issued by Liberty Mutual Fire Insurance Co. <br />Policy Number AS2-631-0041 12-074 <br />Renewal of AS1-631-0041 12-073 <br />Account Number 3-004112 <br />ITEM ONE - Named Insured and Mailing Address <br />ACTS Retirement -Life Communities, Inc. <br />375 Morris Road <br />P.O. Box 90 <br />West Point, PA 19486 <br />• <br />Liberty - <br />Mutual <br />INSURANCE <br />Issuing Office 0390 <br />Issue Date 02/06/2014 <br />Sub Account 0001 <br />Farm of Business of the <br />Business: Corporation named insured is: **See Below <br />Policy Period: The policy period is from 01/01/2014 to 01/01/2015 12:01 A.M. standard time at the <br />Insured's mailing address. <br />In return for the payment of the premium, and subject to all the terms of this policy, we agree wrth you to <br />provide the insurance as stated in this policy. <br />ITEM TWO - Schedule of Coverages and Covered Autos - Refer to Pages 2 and 3 <br />**Health Services; Skilled Nursing Care Facility <br />Pennsylvania Law requires we inform you that this policy does not provide <br />Pennsylvania Uninsured or Underinsured Motorists Coverage. <br />SCHEDULE <br />The declarations are completed on the following pages and on the accompanying "Declarations Extension <br />Schedule(s)". <br />Schedule Premium $227,714 <br />Endorsement Premium <br />Total Estimated Premium $227,714 <br />Other Charge(s) $777.00 <br />Policywriting Minimum Premium $500 <br />Premium will be billed <br />Forms Applicable: See Attached Inventory <br />Proucer 3082 <br />WI LLIS OF PENNSYLVANIA INC <br />100 MATSONFORD RD BLDG 5 STE 200 <br />PO BOX 9052 <br />RADNOR, PA 19087 <br />Producer WASSON P <br />BALA CYNWYD, PA <br />AC 00 03 02 13 <br />8748 <br />Countersigned By: <br />Autho,,bve <br />sen a <br />© 2012 Liberty Mutual Insurance. All rights reserved. <br />Includes copyrighted material of Insurance Services Office, Inc. <br />with its permission. <br />Page 1 of 3 <br />92 <br />