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GENERAL LIABILITY POLICY FORM, In consideration of dollars ($ ) premium and the statements hereinafter set forth in the Schedule of Statements, which statements the assured makes and warrants to be true by the acceptance of this policy, except the statements concerning the compensation of employees which are estimated, the hereinafter called the company, hereby agrees to indemnify of , county of , State of hereinafter called the assured, for a period of months, beginning on the day of

, 190, noon, and ending on the day of , 190 , noon, standard time at the place where this policy has been countersigned: Against loss from the liability imposed by law upon the assured for damages on account of

bodily injuries or death, accidentally suffered while this policy is in force, by any person or persons while within the premises described in the schedule or upon the sidewalk or other ways immediately adjacent thereto provided for the use of employees or the public, subject to the following conditions :

A. The company's liability for loss from an accident resulting in bodily injuries to or in the death of one person is limited to dollars ($ ), and subject to the same limit for each person, the company's total liability for loss from any one accident resulting in bodily injuries to or in the death of inore than one person is limited to dollars ($ ).

B. This policy does not cover loss from liability for injuries or death caused to or by (1) any child employed by the assured contrary to law, or any child employed under fourteen (14) years of age where no statute restricts the age of employment; (2) any person in or about any elevator while in charge of any person under the age fixed by law for elevator attendants, or under the age of eighteen (18) where no age is fixed by law, or caused to or by any person while making additions to or structual alterations in or extraordinary repairs of any elevator plant unless a written permit is granted by the company specifically describing the work; but do elevator may be used for any service while additions, alterations or repairs of any kind are being made ; (3) any person engaged in making additions to or alterations in the building, or repairs of any kind when more than seven (7) days' time is required for the work ; (4) any person before the premises have been fully completed ready for occupancy; (5) any person by reason of the manufacture or presence of any material intended for use as an explosive.

C. Upon the occurrence ot an accident the assured shall give immediate written notice thereof, with the fullest information obtainable at the time, to the office of the company at or to the company's authorized agent. If a claim is made on account of such accident the assured shall give like notice thereof with full particulars. The assured shall at all times render to the company all co-operation and assistance in his power.

D. If thereafter any suit is brought against the assured to enforce a claim for damages on account of an accident covered by this policy the assured shall immediately forward to the company every summons or other process as soon as the same shall have been served on him, and the company will, at its own cost, defend such suit in the name and on behalf of the assured, unless the company shall elect to settle the same or to pay the assured the indemnity provided for in condition A hereot.

E. The assured shall not voluntarily assume any liability, nor shall the assured, without the written consent of the company previously given, incur any expense or settle any claim, except at his own cost, or interfere in any negotiation for settlement, or in any legal proceeding; except that the assured may provide at the time of the accident such immediate surgical relief as is imperative. Whenever requested by the company, the assured shall aid in securing information and evidence and the attendance of witnesses and in effecting settlements and in prosecuting appeals.

F. No action shall lie against the company to recover for any loss under this policy unless it shall be brought by the assured for loss actually sustained and paid in money by the assured in satisfaction of a jadgment after trial of the issue ; nor unless such action is brought within ninety (90) days after final judg. ment against the assured has been so paid and satisfied. The company does not prejudice by this condition any defenses to such action it may be entitled to make under this policy.

G. Ia case of payment of loss under this policy the company shall be subrogated to all rights to the amount of such payment, of the assured against any person or corporation, as respects such loss, and the assured shall execute all papers required and shall co-operate with the company to secure to the company such rights.

H. If the assured carry a policy of another insurer, whether valid or not, against a loss covered by this policy, the assured shall not be entitled to recover from the company a larger proportion of the entire loss than the amount hereby insured bears to the total amount of insurance.

I. If the business of the assured is placed in the hands of a receiver, assignee or trustee, whether by the voluntary act of the assured or otherwise, this policy shall immediately terminate, but such termination shall not affect the liability of the company as to any accidents theretofore occurring. If the assured is a corporation, a change of title, or if a firm or individual, a change of title or of ownership shall in like manner terminate this policy, unless such change is consented to by the company, by an endorsement hereon signed by one of its officers.

J. This policy may be canceled by the company at any time by written notice to the assured stating when the cancellation shall be effective. It may be canceled by the assured by like notice to the company If canceled by the company the company shall be entitled to the earned premium, pro rata, when determined. If canceled by the assured the company shall be entitled to the earned premium calculated at customary short rates. The company's check mailed to the address of the assured as given herein shall be a sufficient tender, but if a premium charge is made for the hazard of employers' liability as provided for in condition N, no return premium shall be payable until a statement of the actual compensation earned by the employees of the assured engaged on the premises during the period the policy was in force shall have been forwarded to the company by the assured.'

K. Any of the company's authorized inspectors shall have the right and opportunity whenever the company só desires to inspect the premises and elevators of the assured; and the company or any of its inspectors may suspend this insurance because

of any detect or dangerous condition found in same. Notice of such suspension and the reason therefor and of the reinstatement of the insurance must be in writing. A return premium for the period of suspension, pro rata, will be paid to the assured on demand.

L. No erasure or change appearing on the face of this policy as originally priated and no change or waiver of any of its terms or conditions or statements shall be valid unless endorsed hereon, and signed by the president, vice-president or one of the secretaries of the company. Notice to or knowledge by any agent or any other person shall not be held to waive any of the terms, conditions or statements hereof.

M. No person shall be deemed an agent of the company unless such person is authorized in writing as such agent by the president, vice-president or one of the secretaries of the company.

N. The premium for this policy is based on the data given in the schedule. If the compensation of employees is greater or less than the estimated sum stated in the schedule, or if the data otherwise given in the schedule is erroneous, the premium charge shall be subject to adjustment on the basis of the rates stated in the analysis of premium given below. The company shall be entitled to examine the pay roll accounts and to check all other items of the schedule whenever it desires to do so.

SCHEDULE. 1. The name of assured, 2. The address of the assured is 3. The assured is (state whether individual, co-partnership, corporation, estate or trustee). 4. The location of the building or buildings, the number and kind of elevators, the wages paid employees, the floor areas and frontages are as follows:

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5.

at $......

If there is more than

State whether pas- State whe- State separate, State area If base. If there is one building, give

senger or freight, therhy- ly estimated of ground ment is frontage on location of each.

sidewalk, onedraulic, wages of office floor in- used as more than story, private electric, men and those cluding all salesroom one street, house, hand hoist, steam of all other parts in- include it state each moving platform plunger. employees en-closed. in num- separately or escalator.

gaged on the

ber. naming premises.

streets.
ANALYSIS OF PREMIUM.
Number.

Kind.
Elevators

for each,

$.
Elevators

at $.
for each,

$
Estimated wages of office men, $.

at....cents per $100,
Estimated wages of all other employees
engaged on the premises, $..

at....cents per $100,

$. Total floor area, all floors included.. square feet at....cents per 100 square feet, $ Street frontage, all frontages included......running feet at....cents per running foot, $.

Total premium.... 6. The kind of business done on the premises is as follows: 7. The assured manages the premises except as follows: 8. The assured occupies the premises except as follows:

9. There is no elevator, escalator or moving platform on the premises except as follows: 10. Al elevators, escalators and moving platforms have been accepted from the builders as satisfactory except as follows:

11. If required by the company the assured agrees to remove the cylinder-bead and submit the piston-rod to examination of the company, unless such examination has been made within three years and the piston-rod found in good order. 12. Neither the premises, nor any part thereof, are undergoing repairs except as follows: 13. No company has canceled or refused to issue liability, elevator or boiler insurance to the assured during the past three years, except as follows: company has insured this risk during the past two years, except as follows: 15. There is no other elevator or general liability insurance carried by the assured on the premises, except as follows: 16. Iospection reports and other notices and correspondence are to be mailed to the assured at the address given above, or to at If to the latter, it is by request of the assured, who acknowledges such person as the proper agent for this purpose.

$.....

14. No

ELEVATOR FORM, The hereinafter called “The Company,” in consideration of dollars ($) premium and the statements hereinafter set forth in the schedule of statements, which statements the assured makes and warrants to be true by the acceptance of this policy, does hereby agree to indemnify of

county of State of , hereinafter called the assured, for a period of months, beginning on the day of

, 190, noon, and ending on the day of , 190 , noon, standard time at the place where this policy has been countersigned, Against loss from the liability imposed by law upon the assured for damages on account of

bodily injuries or death, accidentally suffered while this policy is in force, by any person or persons, while in the car of any elevators described in the schedule, or in the elevator. well or hoist-way thereof or while entering upon or alighting from such car, subject to the following conditions:

A. The company's liability for loss from an accident resulting in bodily injuries to or in the death of one person is limited to dollars ($ ), and, subject to the same limit for each person, the company's total liability for loss from any one accident resulting in bodily injuries to or in the death of more than one person is limited to dollars ($

B. This policy does not cover loss from liability for injuries or death caused by any elevator while in charge of any person under the age fixed by law for elevator attendants, or under the age of eighteen (18) where no age is fixed by law, or caused to or by any person while making additions to or structural alterations in or extraordinary repairs of any elevator plant, unless a written permit is granted by the company specifically describing the work; but no elevator may be used for any service while additions to or alterations in or repairs of any kind are being made.

C. Upon the occurrence of an accident the assured shall give immediate written notice thereof, with the fullest information obtainable at the time, to the office of the company at or to the agent who has countersigned this policy. If a claim is made on account of such accident the assured shall give like notice thereof with tull particulars. The assured shall at all times render to the company all co-operation and assistance in his power.

D. If thereafter any suit is brought against the assured to enforce a claim for damages on account of an accident covered by this policy, the assured shall immediately forward to the home office of the company every summons or other process as soon as the same shall have been served on him, and the company will, at its own cost, defend such suit in the name and on behalf of the assured unless the company shall elect to settle the same or to pay the assured the indemnity provided for in condition A hereof.

E. The assured shall not voluntarily assume any liability, nor shall the assured, without the written consent of the company previously given, incur any expense or settle any claim, except at his own cost, or interfere in any negotiation for settlement or in any legal proceeding; except that the assured may provide at the time of the accident such immediate surgical relief as is imperative. Whenever requested by the company, the assured shall aid in securing information and evidence and the attendance of witnesses and in effecting settlements and in prosecuting appeals.

F. No action shall lie against the company to recover for any loss under this policy unless it shall be brought by the assured for loss ac ually sustained and paid in money by the assured in satisfaction of a judgment after trial of the issue; nor unless such action is brought within ninety (90) days after final judgment against the assured has been so paid and satisfied. The company does not prejudice by this condition any defenses against such action that it may be entitled to make under this policy.

G. In case of payment of loss under this policy the company shall be subrogated to all rights of the assured against any person or corporation, as respects such loss, to the amount of such payment, and the assured shall execute all papers required and shall co-operate with the company to secure to the company such rights.

H. If the assured carry the policy of another insurer, whether valid or not, against a loss covered by this policy, the assured shall not be entitled to recover from the company a larger proportion of the entire loss than amount hereby insured bears to the total amount of his insurance.

I. If the business of the assured is placed in the hands of a receiver, assignee or trustee, whether by the voluntary act of the assured or otherwise, this policy shall immediately terminate, but such termination shall not affect the liability of the company as to any accidents theretofore occurring. If the assured is a corporation a change of title, or if a firm or individual a change of title or of ownership, shall in like manner terminare this policy, unless such change is consented to by the company, by an endorsement hereon, signed by one of its officers.

J. This policy may be canceled by the company at any time by written notice served on or sent by registed letter to the assured sta ing when the cancellation shall be effective. It may be canceled by the assured by a like notice to or registered letter mailed to the company. If canceled by the company, the company shall be entitled to the earned premium pro rata. If caoceled by the assured, the company shall be entitled to the earned premium calculated at customary short rates. The company's check mailed to the address of the assured as given herein shall be a sufficient tender.

K. Any of the company's authorized inspectors shall bave the right and opportunity, whenever the company só desires, to inspect the premises and elevators of the assured; and the company or any of its inspectors may suspend this insurance because of any defect or dangerous condition. Notice of such suspension and the reason therefor, and of the reinstatement of insurance, must be in writing. A return premium for the period of suspension, pro rata, will be paid to the assured on demand,

L. No erasure or change appearing on the face of this policy as originally printed and no change or waiver of any of its terms or conditions or statements shall be valid unless endorsed hereon and signed by the president, or vice-president, or one of the secretaries of the company. Notice to or knowledge by any agent or any other person shall not be held to waive any of the terms, conditions, or statements hereof.

M. No person shall be deemed an agent of the company unless such person is authorized in writing as such agent by the president, or vice-president, or one of the secretaries of the company.

Schedule. 1. Name of assured, 2, Address of assured, (state street, town, county and State where office is located.) 3. The assured is (state whether individual, co-partnership, corporation, estate, or other trustee.) 4. The places where the elevators are located, the number, the number of landings and the kinds of elevators at each place are as follows:

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(State whether passenger, freight, passenger and freight, sidewalk, one-story inside building, or hand hoist.)

5. There is no elevator at any location designated, which is not disclosed above, except as follows:

6. The interest of the assured is that of (state whether owner, lessee or tenant.) 7. All elevators have been accepted from the builders as satisfactory, except as follows: 8. No elevator is now undergoing repairs, except as follows: 9. If required by the company, the assured agrees to remove the cylinder head and submit the piston rod to examination of the company unless such examination has been made within three years and the piston rod found in good order. io. No company bas canceled or refused to issue elevator or boiler insurance to the assured during the past three years, except as follows: 11. No company has insured this risk during the past two years, except as follows: Inspection reports and other notices and correspondence are to be mailed to the assured at address given above or to

• If to the latter, it is by request of the assured, who acknowledges such person as the proper agent for the purpose. 13. There is no other elevator insurance carried by the assured on any of the elevators, except as follows:

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THEATRE FORM. In consideration of dollars ($ ) premium and the statements hereinafter set forth in the schedule of statements, which statements the assured makes and warrants to be true by the acceptance of this policy, except the statements concerning gate receipts, which are estimated the hereinafter called the company, hereby agrees to indemnify of

, county of , State of , hereinafter called the assured, for a period of months, beginning on the day of

, 190 , noon, and ending on the day of , ISO , noon, standard time at the place where this policy has been conntersigned : Against loss from the liability imposed by law upon the assured for damages on account of

bodily injuries or death, accidentally suffered while this policy is in force, by any person or persons while within the premises described in the schedule, or upon the sidewalk or other ways immediately adjacent thereto provided for the use of employees or the public, subject to the following conditions :

A. The company's liability for loss from an accident resulting in bodily injuries to or in the death of one person is limited to dollars ($ ), and, subject to the same limit for each person, the company's total liability for loss from any one accident resulting in bodily injuries to or in the death of more than one person is limited to dollars ($ ).

B. This policy does not cover loss from liability for injuries or death caused to or by (1) any child employed by the assured contrary to law, or any child employed under fourteen (14) years of age where no statate restricts the age of employment; (2) any person in or about any elevator while in charge of any person urder the age fixed by law for elevator attendants or under the age of eighteen (18) where do age is fixed by law, or caused to or by any person wbile making additions to or structural alterations in or extraordinary repairs of any elevator plant unless a written permit is granted by the company specifically describiog the work, but no elevator may be used for any service while additions, alterations or repairs of any kind are being made; (3) any person by reason of the storage or use of any material made to be used as an explosive unless a written permit for the storage or use of such material has been given by the company; (4) ang person engaged in making additions to or alterations in the building or repairs of any kind when more than seven (7) days' time is required for the work; (5) any person as a result of the prosecution on the premises of any business not mentioned in the schedule ; (6) any person as a resnlt, directly or indirectly, of fire et conflagration ; (7) any person before the premises have been fully completed and ready for occupancy. Provided, however, that changes in partitions, scenery, stage fittings and general repairs incidental to stage settings are permitted.

c. Upon the occurrence of an accident the assured shall give immediate written notice thereof, with the fullest information obtainable at the time, to the office of the company at

or to the company's authorized agent. If a claim is made on account of such accident the assured shall give like notice thereof wi h full particulars. The assured shall at all times render to the company all co-operation and assistance in his power.

D. If thereafter any suit is brought against the assured to enforce a claim for damages on account of an accident covered by this policy, the assured shall immediately forward to the company every summons or other process as soon as the same shall have been served on him, and the company wilí, at its own cost, defend such suit in the name and on behalf of the assured unless the company sball elect to settle the same or to pay the assured the indemnity provided for in condition A hereof.

E. The assured shall not voluntarily assume any liability, nor shall the assured, without the written consent of the company previously given, incur any expense or settle any claim, except at bis own cost, nor interfere in any negotiation for settlement, or in any legal proceeding: except that the assured may provide at the time of the accident such immediate surgical relief as is imperative. Whenever requested by the company, the assured shall aid in securing information and evidence and the attendance of witnesses and in effecting settlements and in prosecuting appeals.

F. No action shall lie against the company to recover for any loss under this policy unless it shall be brougbt by the assured for loss actually sustained and paid in money by the assured in satisfaction of a judgment after trial of the issue; nor unless such action is brought within pinety (90) days after final judge ment against the assured has been so paid and satisfied. The company does not prejudice by this condition any defenses to such action it may be entitled to make under this policy.

G. In case of payment of loss under this policy the company shall be subrogated to all rights to the amount of such payment, of the assured against any person or corporation, as respects such loss, and the assured shall execute all papers required and shall co-operate with the company to secure to the company such rights.

H. If the assured carry a policy of another insurer, whether valid or not, against a loss covered by this policy, the assured shall not be entitled to recover from the company a larger proportion of the entire loss than the amount hereby insured bears to the total amount of his insurance.

I. If the business of the assured is placed in the hands of a receiver, assignee or trustee, whether by the voluntary act of the assured or otherwise, this policy shall immediately terminate, but such termination shall pot affect the liability of the company as to any accidents theretofore occurring. If the assured is a corporation, a change of title, or if a firm or individual a change of title or of ownership shall in like manner terminate this policy, unless such change is consented to by the company, by an endorsement hereon, signed by one of its officers.

J. The premium charged for this policy is based on the data as to the number of elevators, seats or as to gate receipts. The company shall be entitled to inspect the premises and the books of the assured as respects these items. If the number of seats or the gate receipts are not correctly stated the premium shall be adjusted according to the data on the basis of the rate shown in the schedule.

K. This policy may be canceled by the company at any time by written notice to the assured, stating when the cancellation shall be effective. It may be canceled by the assured by like notice to the company. If canceled by the company the company shall be entitled to the earned 'premium, pro rata, when determined. If canceled by the assured the company shall be entitled to the earned premium calculated at customary short rates. The company's check mailed to the address of the assured as given herein shall be a sufficient tender, but if any portion of the premium charge is based upon the gate receipts as provided for in condition J, no return premium shall be payable until a statement of the actual amount of gate receipts received during the period the policy was in force shall have been forwarded to the company by the assured.

L. Any of the company's authorized inspectors shall have the right and opportunity whenever the company so desires to inspect the premises and elevators of the assured; and the company or any of its inspectors may suspend ihis insurance because of any defect or dangerous condition found in same. Notice of such suspension and the reason therefor and of the reinstatement of the insurance must be in writing. A return premium for the period of suspension, pro rata, will be paid to the assured on demand.

M. No erasure or change appearing on the face of this policy as originally printed and no change or waiver of aty of its terms or conditions or statements shall be valid unless endorsed hereon, and signed by the president, vice-president or one of the secretaries of the company. Notice to or knowledge by any agent or any other person shall not be held to waive any of the terms, conditions or statements hereof.

N. No person shall be deemed an agent of the company unless such person is authorized in writing as such agent by the president, vice-president or one of the secretaries of the company.

0. The assured shall, whenever requested, furnish the company with a written statement of the amount of the gate recepts during any part of the period of the policy, and at the end of the period of the policy the assured shall furnish the company with such statement covering the full period of the policy. The rendering of any estimate or statement or any settlement shall not bar the examination herein provided for nor the company's right to additional premiums.

SCHEDULE. 1. Name of assured 2. Address of assured 3. The assured is (state whether individual, co-partnership, corporation, estate or trustee.) 4. The premises are located as follows: (state street, town, county and State.) 5. The interest of the assured is that of (owner, lessee or tenant.) 6. The building is constructed or provided as follows: (a) all external walls are of masonry, with or without a steel or iron frame, except as follows: (b) All interior walls and partitions are of masonry (c) The main floor is less than six feet above the street level, except as follows: (d) There are exits from all floors or galleries passing from such floors directly through the external walls or wing walls of masonry to independent staircases, except as follows: (e) There is an asbestos or fireproof curtain in front of stage, except as follows: (1) There is an automatic sprinkler system installed over the stage (g) The exhibitions given are as follows: (state whether those usual in theatres proper, such as dramatic entertainments, operas, concerts, or lectures, or continuous performances, or athletics, or horse show, or dog show, or agricultural exhibition, or horticultural exhibition.) (h) Such exhibition is confined to the premises mentioned and does not include any open-air place, roof gardens excepted, or other place than the permanent construction described hereinbcfore, except as follows: 7. The interest of the assured in the entertainments to be given is as follows: (state whether the entertainments are given by the assured or whether he leases the premises to persons who give the entertainments.) 8. The elevators are as follows:

(state whether passenger, freight, passenger and freight, sidewalk or one-story.)

1

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seats......

ANALYSIS OF PREMIUM.
Number.

Kind.
Elevators..

.at $. ...for each.
Elevators..

..at $. ... for each. Seating capacity

.cents for each. Estimated gate receipts $.

.at.

per cent. Total premium...... 10. There is no elevator, escalator or moving platform at any location mentioned which is not disclosed above. 11. There is no outstanding dispute with the maker of any elevator as to its condition. 12. All elevators have been accepted from the builders as satisfactory. 13. Neither the elevators nor the premises are undergoing repairs, except as follows: 14. The machinery used in the premises is that usual to such buildings, except

15. No company has canceled or refused to issue liability, elevator or boiler

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