ge URGE United States Liability Insurance Company
“ “ 1190 Devon Park Drive, Wayne, Pennsylvania 19087
POLICY DECLARATIONS A Member Company of United States Liability Insurance Group
No. SE 1030676
NAMED INSURED AND ADDRESS:
VIRGINIANS FOR ALTERNATIVES TO THE DEATH ‘
PENALTY Flat cancellation
PO BOX 12222 not allowed
RICHMOND, VA 23241
POLICY PERIOD: (MO. DAY YR.) From: 11/21/2021 To: 11/23/2021 12:01 A.M. STANDARD TIME AT YOUR
MAILING ADDRESS SHOWN ABOVE
FORM OF BUSINESS: Non-Profit Corporation
BUSINESS DESCRIPTION: Special Event
IN RETURNIFOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE
WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
PREMIUM
Commercial Liability Coverage Part $195.00
Wholesaler Broker Fee $50.00
TOTAL: $245.00
Coverage Form(s) and Endorsement(s) made a part of this policy at time of issue
See Endorsement EOD (1/95)
Agent: BLOSS & DILLARD, INC. (1029) Issued: 11/05/2021 2:18 PM
P.O. Box 7878
Huntington, WV 25778 Sb nan yy
Broker: Ball Martin Insurance : Vint —
PO Box 35632 ay ‘Authorized sr a
North Chesterfield, VA 23235
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS,
COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF,
UPD (08-07) COMPLETE THE ABOVE NUMBERED POLICY.
EXTENSION OF DECLARATIONS
Policy No, SE 1030676 Effective Date: 11/21/2021
12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS
FORMS AND ENDORSEMENTS
The following forms apply to the Commercial Liability coverage part
Endt# Revised Description of Endorsements
cGo001 12/07 Commercial General Liability Coverage Form
CG0068 05/09 Recording And Distribution Of Material Or Information In Violation Of
Law Exclusion
CG0179 07/10 Virginia Changes
CG2011 04/13 Additional Insured - Managers or Lessors of Premises
CG2107 05/14 Exclusion - Access Or Disclosure Of Confidential Or Personal
Information And Data-Related Liability - Limited Bodily Injury Exception
Not Included
CG2109 06/15 Exclusion - Unmanned Aircraft
CG2136 03/05 Exclusion - New Entities
CG2139 10/93 Contractual Liability Limitation
CG2144 04/17 Limitation of Coverage to Designated Premises, Project or Operation
CG2147 12/07 Employment-Related Practices Exclusion
CG2173 O15 Exclusion Of Certified Acts Of Terrorism
IL0017 11/98 Common Policy Conditions
1L0021 09/08 Nuclear Energy Liability Exclusion Endorsement
IL0138 41/11 Virginia Changes-Cancellation and Nonrenewal
Jacket 07/19 Policy Jacket
L427 01/20 Exclusion for Fireworks and Other Pyrotechnic Devices
L535 03/15 Exclusion - Products-Completed Operations Hazard Other Than Food
Or Beverage Products
L-206 VA 03/13 Fully Earned Premiun Endorsement
L-224 127 Punitive or Exemplary Damages Exclusion
L-387 12/19 Exclusion - Mechanical Riding Devices and Mechanical Amusement
Devices
L-423 02/11 Exclusion For Structure Collapse
L-428 04/15 Absolute Firearms Exclusion
L-536 09/09 Exclusion - Participation In Athletic Activity, Physical Activity Or Sports
L-599VA 10/12 Absolute Exclusion For Pollution, Organic Pathogen, Silica, Asbestos
And Lead With A Hostile Fire Exception
L-606 02/11 Exclusion For Injury To Performers, Entertainers And Participants
L-607 10/16 Exclusion for Climbing, Rebounding and Interactive Games and Devices
L-609 02/11 Animal Exclusion
L-610 04/15 Expanded Definition Of Bodily Injury
L-656 12/7 Extension of Coverage - Committee Members
L-686 10/12 Absolute Exclusion for Liquor and Other Related Liability
L-816 11/18 Amendments of Conditions - Limits of Insurance Under Multiple
Coverage Parts
L-820 12/18 Special Events Blanket Additional Insured Endorsement
LLQ 101 09/15 Expanded Definition of Employee
EOD (01/95) Alll other terms and conditions remain unchanged. Page 1 of 2
Policy No, SE 1030676
EXTENSION OF DECLARATIONS
Effective Date: 11/21/2021
12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS
FORMS AND ENDORSEMENTS
LLQ 102
LLQ368
SPE 300
SPE 312
TRIADN
VA Notice
02/15
08/10
05/09
03/15
12/20
01/21
Event Vendor, Exhibitor And Contractor Exclusion
Separation Of Insureds Clarification Endorsement
Special Events Property Damage Amendment
Who Is An Insured
Disclosure Notice of Terrorism Insurance Coverage
Virginia Notice
EOD (01/95)
Alll other terms and conditions remain unchanged. Page 2 of 2
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
Policy No. SE 1030676 Effective Date: 11/21/2021
12:01 STANDARD TIME
LIMITS OF INSURANCE
Each Occurrence Limit $1,000,000
Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000
Medical Expense Limit (Any One Person) $1,000
Damages To Premises Rented To You (Any One Premises) $100,000
Products/Completed Operations Aggregate Limit See L-535
General Aggregate Limit $2,000,000
LIABILITY DEDUCTIBLE $0
LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY
Location Address Territory
1 990 Hilton Heights Road, Charlottesville, VA 22901 004
PREMIUM COMPUTATION
Advance Premium
JEvt # Classification Code No. — Premium Basis Pr/iCo All Other Pr/Co All Other
1 Fundraiser - Luncheon (applicant is the host of the 00422 100 Attendees NIA 195.000 N/A $195
event)
1 Additional insured - Blanket - Special Events 49950 1 Per Additional NIA 0.000 N/A $0
Insured
1 Per Additional NIA 0.000 N/A $0
1 Additional Insured - Property Owner or Lessors of 49950
Premises Insured
MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $195
TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $195 MP
(This Premium may be subject to adjustment.) MP - minimum premium
Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue’
See Form EOD (01/95) and Form SOE (03/10)
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
includes material of ISO G Risk Services, Inc., with ts permission.
CL150 (10/03) Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988 Page 1 Of 1
EXTENSION OF DECLARATIONS
Regardless of the dates shown on the Declarations, this insurance applies only for the location(s), event(s) and
date(s) specified in this ion of D
Policy No. SE 1030676
SCHEDULE OF EVENTS
Event Start Date End Date
Fundraiser - Luncheon (applicant is the host of the event) 41/21/2021 11/21/2021
Location(s):
990 Hilton Heights Road, Charlottesville, VA 22901
Subject to the terms and conditions of this policy, is provided for a of
twenty-four (24) hours after the scheduled end date of an event shown above.
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD,
SOE (03/10) All other terms and conditions remain unchanged, Page 1 of 1
POLICY NUMBER: SE 1030676 COMMERCIAL GENERAL LIABILITY
CG 20 11 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person(s) Or Or izati ) (A
Effective Date: 11/21/2021
RICH CHARLOTTESVILLE HOTEL DBA DOUBLE TREE BY HILTON CHARLOTTESVILLE & GREENWOOD
HOSPITALITY MANAGEMENT LLC.
9980 HILTON HEIGHTS RD
CHARLOTTESVILLE, VA 22901
Designation of Premises (Part Leased To You):
990 HILTON HEIGHTS ROAD
CHARLOTTESVILLE, VA 22901
Additional Premium: $
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section Il - Who is An Insured is amended to include
as an additional insured the person(s) or organization(s)
shown in the Schedule, but only with respect to liability
arising out of the ownership, maintenance or use of that
part of the premises leased to you and shown in the
Schedule and subject to the following additional
exclusions:
This insurance does not apply to:
1.Any "occurrence" which takes place after you cease
to be a tenant in that premises.
2.Structural alterations, new construction or demolition
operations performed by or on behalf of the person
(s) or organization(s) shown in the Schedule.
However:
1.The insurance afforded to such additional insured only
applies to the extent permitted by law; and
CG 20 11 04 13
© Insurance Services Office, Inc., 2012
2. If coverage provided to the additional insured is
required by a contract or agreement, the insurance
afforded to such additional insured will not be broader
than that which you are required by the contract or
agreement to provide for such additional insured.
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section lil - Limits Of Insurance:
If coverage provided to the additional insured is required
by a contract or agreement, the most we will pay on
behalf of the additional insured is the amout of
insurance:
1,Required by the contract or agreement; or
2.Available under the applicable Limits of Insurance
shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.
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