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ALL PREMISES YOU OWN, RENT OR OCCUPY <br />LOCATION NUMBER <br />ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY <br />See CG DS01 - Supp - Classification Schedule <br />CLASSIFICATION <br />ATTACH <br />THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE <br />FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. <br />Countersigned:05/18/2017 <br />CLASSIFICATION <br />AND PREMIUM <br />LOCATION <br />CLASSIFICATION <br />CODE <br />PREMIUM <br />RATE <br />ADVANCE PREMIUM <br />Prem/ <br />Prod/Comp <br />Prem/ <br />Prod/Comp <br />NUMBER <br />NO. <br />BASE <br />OPS <br />OPS <br />OPS <br />Ops <br />See CG DS01 - <br />Supp - Classification Schec <br />ule <br />STATE TAX OR OTHER (if applicable) $ PER ILDS00 <br />TOTAL PREMIUM (SUBJECT TO AU- <br />DIT) $ <br />PREMIUM SHOWN IS PAYABLE: <br />AT INCEPTION Incl <br />AT EACH ANNIVERSARY $ <br />(IF POLICY PERIOD IS MORE THAN ONE YEAR AND PRE- <br />MIUM IS PAID IN ANNUAL INSTALLMENTS) <br />AUDIT PERIOD (IF APPLICABLE) <br />❑ ANNUALLY <br />❑ SEMI- <br />❑QUARTERLY <br />❑ MONTHLY <br />ANNUALLY <br />ATTACH <br />THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE <br />FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. <br />Countersigned:05/18/2017 <br />By: <br />(Date) <br />(Authorized Representative) <br />McNeil & Company, Inc. <br />NOTE <br />OFFICERS' FACSIMILE SIGNATURES MAY BE INSERTED HERE, ON THE POLICY COVER OR ELSE- <br />WHERE AT THE COMPANY'S OPTION. <br />88 <br />Page 2 of 2 © ISO Properties, Inc., 2000 CG DS 01 10 01 <br />