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1. Name of assured 2. Office address of assured (name of street, town, county and State). 3. Nature of business 4. Location of buildings 5. Portion of buildings occupied by assured 6. The floors are (state whether single or double). 7. The sprinkler system is (give name of system). 8. Number sprinkler heads in use 9. The heads are (state whether upright or pendant). 10. The sprinkler system was erected by in 190 II. It is supplied with an automatic alarm, which is connected with an outside central station, except as herein stated 12. The system is (state whether " wet" or "dry."). 13. The source of water supply is (public or private). 14. If from public water supply the local pressure is 15. The capacity of tank is gallons. 16. The tank is filled by 17. It is provided with a "tell tale" 18. The valves are located as follows: 19. There is a cut-off valve on each floor, except as herein stated. 20. All cut-off valves are strapped open, except as herein stated 21. There is an electric alarm signal on each floor, connecting with the engine room, and said signal will be used for the sole purpose of notifying the engineer of an accident to the sprinkler system, except as herein stated 22. Protection against freezing is provided as follows: 23. The roof is made of (state material). 24. There is a regular watchman on duty within the premises of the assured described above at all times (including Sundays and holidays), when same is not open for business. 25. He is familiar with the sprinkler system. 26. He has a time detector, except as herein stated 27. Such a watchman will be so employed during the full term of this policy 28. This insurance shall apply specifically as per schedule on next page. 29. The sprinkler system has never caused damage, except as herein stated 30. No other similar insurance carried, except as herein stated 31. There is no information tending to increase the hazard, except as herein stated

The risk to commence at noon, standard time, at the place where the policy is countersigned day of Dated

assured.

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EMPLOYEES' COLLECTIVE POLICY, ISSUED EXCLUSIVELY BY THE

OCEAN ACCIDENT AND GUARANTEE. Whereas, (hereinafter called the assured), under date of has made application to

(hereinafter called the corporation), for an indemnity against claims for personal injuries, and for insurance on behalf of said assured's employees against personal injuries as hereinafter specified, having made certain statements therein upon which this policy is granted, and said statements are incorporated herein as warranties, except as to the matters which are declared as estimates only, and has paid to the corporation the sum

dollars as the premium for such indemnity for calendar months from the day of 190 , at noon, standard time, at the place where this policy has been counter. signed.

CONDITIONS OF CONTRACT. It is hereby agreed as follows, that the corporation will pay, subject to the subjoined general agreements, as conditions, in respect of any loss from common law or statutory liability for damages on account of bodily injuries, accidentally suffered within the period of this policy by any employee of the assured while on duty on the premises mentioned in the schedule hereto, or upon the ways immediately adjacent thereto, provided for the use of such employees or the public, in and during the operation of the trade or business described in the said schedule.

A. The full amount of such sum for which a settlement may be effected by the corporation's representative.

B. Eighty per cent. of such sum not exceeding the wages of the injured person for which the assured shall, in his discretion, effect a compromise with the injured person where, in the judgment of the assured, the said assured is liable for the injury, provided a full release be obtained and rendered to the corporation within six months of the date of the accident.

C. Eighty per cent of all medical, surgical, ambulance or funeral expenses, such eighty per cent, not to exceed $100 for any one person, for which the assured shall render himself liable, on a full discharge given to the corporation by the assured for such outlay after payment thereof by the assured, and within six months of the date of the accident.

D. Eighty per cent. of such sum which the assured shall pay upon a final judgment recovered against him after trial of the issue.

It is further agreed that the corporation will pay in respect of any accidental bodily injury caused by violent external and visible means suffered within the period of this policy by any employee of the assured while on duty as aforesaid.

E. In the event of death from such injury within ninety days thereof, a sum equal to the wages of the employee earned in his occupation during the preceding twelve months, such sumonot to exceed $1,500 for any one person.

F. In the event of totally disabling injuries suffered as aforesaid, a sum equal to one-half the weekly wages of the injured employee based upon the amount disclosed in the schedule of this policy, for a period not exceeding 52 weeks.

The corporation's liability for any payment made under all of the six preceding clauses, A, B, C, D, E, F, in respect of any one person is limited to $8,000 and subject to the same limit for any one person, the total inability for any one accident is limited to $20,000.

GENERAL AGREEMENTS. 1. The assured, upon the occurrence of an accident shall give immediate written notice thereof, with the fullest information obtainable at the time, to the head office of the corporation, New York City, or to its duly authorized local agent. He shall give like notice with full particulars of any claim that may be made on account of such accident, and shall at the time render to the corporation all co-operation and assistance in his power. The assured shall not interfere in any negotiations for settlement, or in any legal proceeding, without the consent of the corporation previously given in writing. The assured, when requested by the corporation, shall aid in securing information, evidence and the attendance of witnesses, and in effecting settlements and in prosecuting appeals, and shall furnish the bond necessary for prosecuting any appeal.

2. If any suit is brought against the assured to entorce a claim for damages on account of an accident covered by this policy, the assured shall immediately torward to the head office of the corporation every summons or other process as soon as the same shall have been served on him, and the corporation will, at its own cost, defend against such proceeding in the name and on behalf of the assured, and shall have the absolute night of determining whether any judgment or order therein shall be appealed.

3. This policy does not cover loss from liability for injuries to, or caused wholly or in part by, any child employed by the assured contrary to law; nor to, or caused wholly or in part, by any child so employed under fourteen years of age, unless such child be included in the employees given in the schedule hereto.

4. If the assured carry a policy of another insurer, whether valid or not, against a claim arising under this policy, he shall not be entitled to recover from the corporation a larger proportion of the loss than the sum hereby issued bears to the whole amount of the insurance. If the assured has any other similar policy in this corporation, the assured must elect under which policy all claims arising out of any one accident shall be treated and the corporation shall not be responsible under any other such policy. 5. No action

shall be maintained by the assured against the corporation for the recovery or any loss under this policy except for reimbursement for said eighty per cent. of a final judgment recovered against the assured after trial of the issue in an action commenced within the time limited by the statute of the State where such judgment may be recovered. Such an action by the assured against the corporation shall not be maintained unless commenced within sixty days after recovery of judgment against the assured for the loss actually sustained by payment thereof. The corporation does not prejudice by this clause any defenses to such action which it may be entitled to make under this policy.

6. The premium is based on the compensation to employees to be expended by the assured during the period of this policy. If the compensation actually paid exceeds the sum stated in the schedule hereinafter given, the assured shall pay the additional premium earned; if less than the sum stated, the corporation will return to the assured the unearned premium pro rata; but the corporation shall first retain not less than fifty dollars ($50), it being understood and agreed that this sum shall be the minimum earned premium under this policy.

7. This policy may be canceled by the corporation at any time by notice in writing to the assured stating specifically when the cancellation shall be effective. It may also be cancelled by the assured by like notice in writing to the corporation, provided the premium shall have been paid. In either case the earned premium shall be computed on the pay-roll for the year as indicated by the actual expenditure for wages during the time the policy shall have been in force. If canceled on the corporation's motion, the corporation shall pay or tender to the assured the unearned premium pro rata, when determined. If canceled at the request of the assured, the corporation shall retain the customary short rate premium and return the balance, if any, to the assured when determined. The check of the corporation mailed to the address of the assured as given herein shall be a sufficient tender, but the return premium shall not be payable until the assured shall have rendered to the corporation a full statement of wages expended to the date of cancellation. In any case the minimum earned premium stated in clause 6 shall be retained by the corporation.

8. The corporation shall have the right and opportunity at all reasonable times to examine the books of the assured so far as they relate to the compensation paid to his employees, and also to inspect the plant, works, machinery and appliances used in his business. "The assured shalí, if requested, furnish the corporation with a written statement of the amount of such compensation during any part of the policy period, under oath if required.

9. No condition or provision of this policy shall be waived or altered by anyone unless by written consent of the general manager of the corporation, nor shall notice to any agent, nor shall knowledge possessed by any agent or by any other person, be held to eftect a waiver or change in this contract or in any part of it.

10. This policy covers the employees on the pay-roll of the assured engaged in the maintenance in good condition of ihe existing ways, works, plants and machinery, but extraordinary alterations and repairs thereto, by which is meant the demolition of existing walls and structures, or the erection of new buildings and brick or stone partitions are not covered hereby. (This clause does not apply in the case of contractors engaged in construction work.)

u. No action shall be brought under this policy except by and in the name of the assured.

In witness whereof, the corporation, 'has caused this policy to be signed by its general manager, but the same shall not be binding upon the corporation until countersigned by a duly authorized representative of the corporation. Countersigned at this

190 , by

Authorized Agent.

APPLICATION, I. Name of assured 2. Address of assured 3. The trade of business in respect of which this insurance is desired is fully disclosed in the schedule following:

day of

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EMPLOYEES AT EACH AGE UNDER 14 YEARS OF AGE, EMPLOYED ACCORDING TO LAW.

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The total expenditure of wages for the last previous twelve months was $

, 190

EMPLOYERS' LIABILITY POLICY OF NEW AMSTERDAM

CASUALTY COMPANY. In consideration of dollars ($ ) premium, and of the statements contained in the schedule attached hereto and hereby made a part hereof, which statement the assured makes on the acceptance of this policy and warrants to be true, the New Amsterdam Casualty Company (herein called the company), does hereby agree to indemnify

of , county of , State of (herein called the assured), for the term of months, beginning on the day of

at noon, and ending on the day of , 190 , standard time, at the place where this policy has been countersigned, subject to the following special and general agreements which are to be construed as coordinate as conditions: Against loss from common law or statutory liability for damages on account of bodily injuries,

fatal or non-fatal, accidentally suffered within the period of this policy by any employee or employees of the assured while on duty within the factory, shop or yards mentioned in the schedule hereinafter given, or upon the ways immediately adjacent thereto provided for the use of such employees or the public, in and during the operation of the trade or business described in the said schedule, and against the expense of defending any suit for such damages.

SPECIAL AGREEMENTS. A. The company's liability for an accident resulting in injuries to, or in the death of one person is limited to dollars, ($ ), and, subject to the same limit for each person, the total liability for any one accident resulting in injuries to, or in the death of several persons is limited to dollars ($ ).

B. This policy does not cover loss from liability for injuries as aforesaid caused by or happening in or about any elevator plant, por caused by the explosion, collapse or rupture of any steam boiler, unless such elevator plant and such boiler are enumerated in the schedule hereinafter given; nor for injuries to or caused by any person unless his wages are included in the estimated wages hereinafter set forth and he is on duty at the time of the accident in an occupation hereinafter described, at the place or places mentioned in the schedule; but drivers and drivers' helpers while on duty in the employ of the assured at places other than those mentioned in the schedule, shall not be excluded from this insurance, provided they are enumerated and their estimated wages are stated in warranty 4 of the said schedule.

C. This policy does not cover loss from liability for injuries to, or caused by any person in connection with the making of additions to or alterations in any building or plant occupied by the assured, nor in connection with wrecking. Ordinary repairs, when made by employees whose wages are included in the estimaied pay-roll, are permitted.

D. The premium is based on the compensation to employees to be expended by the assured during the period of this policy. If the compensation actually expended exceeds the sum stated in the schedule hereinafter given, the assured shall pay the auditional premium earned; if less than the sum stated, the company will return to the assured the unearned premium, pro rata ; but the company shall first retain not less than the minimum premium stated in said schedule, it being understood and agreed that this sum shall be the minimum carned premium under this policy.

E. This policy may be canceled by the company at any time by notice in writing to the assured stating specifically when the cancellation shall be effective. It may also be canceled by the assured by like notice in writing to the compariy, provided the premium shall have been paid. In either case the earned premium shall be computed on the compensation to employees for the year as indicated by the actual expenditure for such compensation during the time the policy shall have been in force. If canceled at the company's motion the company shall pay

or tender to the assured the unearned premium pro rata, when determined. If canceled at the request of the assured, the company shall retain the customary short rate premium and return the balance, if any, to the assured when determined. The check of the company mailed to the address of the assured as given herein shall be a sufficient tender, but the return premium shall not be payable until the assured shall have rendered to the company a full statement of compensation to employees expended to the date of cancellation. In any case the minimum earned premium stated in clause D and twenty-five per cent. for expenses, shall be retained by the company:

F. The company shall have the right and opportunity at all reasonable times to examine the books of the assured so far as they relate to the compensation paid to his employees, and also to inspect the plant, works, machinery and appliances used in his business. The assured shall, when requested, furnish the company with a written statement of the amount of such compensation during any part of the policy period under oath if required.

GENERAL AGREEMENTS. 1. The assured upon the occurrence of an accident shall give immediate written notice thereof with the fullest information obtainable at the time to the home office of the company in New York city, or to its duly authorized agent. He shall give like notice with full particulars of any claim that may be made on account of such accident, and shall at all times render to the company all co-operation and assistance in his power.

2. If thereafter any suit is brought against the assured to enforce a claim for damages 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 defend against such proceeding in the name and on behalf of the assured, or settle the same, unless it shall pay to or on account of the assured an amount equal to the indemnity provided for in clause A of special agreements as limited

3. The assured shall not settle any claim except at his own cost, nor incur any expense, nor interfere in any negotiation for settlement or in any legal proceeding, without the consent of the company previously given in #riving; but he may provide at the time of the accident such immediate surgical relief as is imperative.

therein.

The assured when requested by the company shall aid in securing information, evidence and the attendance of witnesses and in eftecting settlements and in prosecuting appeals.

4. This policy does not cover loss from liability for injuries to, or caused wholly or in part by, any child employed by the assured contrary to law; nor to, or caused wholly or in part by, any child employed under fourteen years of age where no statute restricts the age of employment.

5. If the assured carry a policy of another insurer, whether valid or not, against a claim arising under this policy, he shall not be entitled to recover from the company a larger proportion of the loss than the sum hereby insured bears to the whole amount of the insurance. If the assured has any other similar policy in this company the assured must elect under which policy all claims arising out of any one accident shall be treated and the company shall not be responsible under any other such policy.

6. No assignment of interest under this policy shall bind the company unless the written consent of the company is indorsed hereon signed by one of its officers at the home office.

7. No action shall lie against the company as respects any loss under this policy unless it shall be brought by the assured himself to reimburse hím for loss actually sustained and paid by him in satisfaction of a final judgment within sixty days from the date of such judgment and after trial of the issue. No such action shall lie unless brought within the period within which a claimant might sue the assured for damages unless at the expiry of such period there is such an action pending against the assured, in which case an action play be brought against the company by the assured within sixty days after final judgment has been rendered and satisfied as above. The company does not prejudice by this clause any defenses to such action which it may be entitled to make under this policy.

8. In case of payment of loss under this policy the company shall be subrogated to all claims or rigbes of the assured in respect of such loss against any person or persons, and the assured shall execute any and all papers required and shall co-operate with the company to secure to it said rights.

9. In any matter relating to this insurance no person shall be deemed an agent of the company who is not duly authorized in writing.

10. No condition or provision of this policy shall be waived or altered by any one unless by written consent of an officer of the company at the home office, nor shall notice to any agent nor shall knowledge possessed by any agent or by any other person be held to effect a waiver or change in this contract or in any part of it.

In witness whereof The New Amsterdam Casualty Company has caused this policy to be executed at the City of New York, but the same shall not be binding upon the company until countersigned by a doly authorized representative of the company.

Schedule. 1. Name of assured. 2. Address of assured (Name street, town, county and State where office is located.) 3. The assured is (State whether individual, co-partnership, corporation, or estate.) 4. The factories, shops or yards are located as stated below. The trade or kind of business carried on at each such location, and the number of employees and the pay-roll at each such location are as tollows: (Enter in “Trade or Kind of Business" column the precise manual classification. Enter each manual classification separately when pay-roll is divided under manual rule. Give number of em. ployees, pay-roll, premium rate, and amount of premium, opposite each classification. If drivers and drivers' helpers are to be covered, they must be enumerated and their pay-roll must be stated.)

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5. The operations carried on are those usual to the trade or kind of business described herein. 6. There are no steam-power boilers on the premises except as follows: 7. There are no passenger of freight elevators on the premises except as follows: 8. No power is used except as tollows: No chemicals are used except as follows: 10. No explosives are used except as follows: 11. No stamping of sheet or other metal is done by power or other presses fed by hand, except as follows: (State here the number of such hand-fed presses, and state separately the number of employees and the pay-roll on such presses, as provided in manual rule.) 12. The estimated pay-roll covers the wages of all persons employed by the assured on the premises mentioned in statement No. 4, including drivers and drivers' helpers if enumerated above and executive officers, office employees and piece-workers, except as follows: 13. The following similar insurances are now carried: Employers' liability, $ of company, Public liability, $ ; name of company,

Workmen's collective, $ name of company, Boiler, $ ; name of company,

Elevator, $

; name of company, Teams, $ ; name of company,

14. Valid insurance in amounts not less than stated in warranty 13 will be carried during the term of this policy. 15. This risk has not been refused or canceled by any compauy during the past three years except as follows:

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16. The total expenditure for wages for the last calendar year (ended Decembr 31, 190 17. The minimum premium for this policy is $

,) was $

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