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hereby insured bears to the whole amount of the insurance against such casualty carried by the assured: and if any of such other insurance shall be that of the company, the assured must elect under which polie of the company any claim arising out of such casualty shall be made, and thereafter the company shall not be liable to the assured in connection with such casualty under any other policy.

9. No assignment of interest under this policy shall bind the company until the written consent of company shall have been endorsed hereon by one of its executive officers.

io. No condition or provision of this policy shall be waived or altered save in writing by an executive officer of the company, and no notice given to or possessed by any agent or other person shall be held is effect a waiver or change in this contract.

11. No person, unless duly authorized by the company in writing, shall be deemed to be an agent at this company as regards this policy or the insurance represented hereby,

12. The statements contained in the accompanying schedule are hereby made a part of this coatract; which statements the assured makes on the acceptance of this policy and warrants to be true, saving as to those which are declared to be estimates only.

SCHEDULE. 1. Applicant 2. Address : No.

county

3. Applicant is (individual, partnership, corporation or estate.) 4. Enter in trade or kind of business" column precise manual classification. Enter each manual classification separately when pay roll is divided under manual rule. Give number of employees, pay roll, premium rate and amount of premium opposite eară classification. Drivers and drivers' helpers may be covered, if their wages are included in estimated par roll.

town

State

Kinds of Work as in Manual Place Where Work is to be
Classification,

Done.

Estimated Number

of Employees.

Estimated
Pay Roll for
Policy Term.

Premium

Rate Per $100 of Wages.

Premian.

5. Operations carried on are those usual to kind of business described, except

6, Number of boilers ; type

7. There are no passenger or freight elevators on premises, except No power is used, except 9. No chemicals or explosives are used, except 10. No stamping of sheet or other metal is done by power or other presses fed by hand, except (state number of such hand-fed presses, and state separately in schedule above the number of employees and the pay roll on such presses.) 11. Estimated pay roll covers wages of all persons employed on premises, including executive officers, office men, piece workers, drivers and drivers' helpers, except

12. The following similar insurances are now carried: Employers' Liability, $ ; company, Public Liability, $ company, Elevator Liability, $ i company,

Teams' Liability, $ ; company Workmen's Wages, $ i company,

Boiler, $ i company, insurance, in amounts not less than stated in warranty 12, will be carried during the term of this policy. 14. This risk has not been refused or canceled by any company within three years, except

15. Total expenditure for wages for last calendar year (ended December 31, 190 ) was $ 16. Minimum premium for this policy, $

.

12. Valid

EMPLOYERS AND PUBLIC LIABILITY POLICY OF CASUALTY

COMPANY OF AMERICA. Against loss from common law or statutory liability for damages on account of bodily in

juries, fatal or non-fatal, accidentally suffered during the term of this policy within the factory, shop or yards mentioned in the schedule hereinafter given, or upon the ways immediately adjacent thereto, provided for the use of employees and the public, in and during the operation of the trade or business described in said schedule (a) by any employee or employees of the assured (b) by any person or persons not employed by the assured.

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

B. The company's liability for an accident resulting in injuries to or in the death of one person not employed by the assured is limited to dollars ($ ), and, subject to the same limit for each person, the total liability for one accident resulting in injuries to or in the death of several persons not employed by the assured is limited to dollars ($

C. This policy does not cover loss from liability for injuries as aforesaid to persons not employed by the assured, caused by or happening in or about any elevator plant or caused by horses or vehicles; or for injuries to or caused by any employee unless his compensation is included in the estimate hereinafter set forth and he is employed in an occupation hereinafter described, at the place or places mentioned in the Schedule ; or to drivers and drivers' helpers, unless their compensation is included in the estimated pay roll, or they are drivers and helpers of teams for which the assured carries concurrent teams insurance in this .company.

D. The premium is based on the compensation to employees to be expended by the assured during he period of this policy. Whenever employees are compensated in whole or in part by store certificates, joard, merchandise, credits or any other substitutes for cash, the amount of compensation covered by such ubstitutes shall be included in the pay roll. At the end of the policy period, the assured shall report to the ompany the actual compensation paid to employees. If the compensation actually paid exceeds the sum amed in the schedule hereinafter given, the assured shall pay the additional premium earned ; if less than be sum stated, the company will return to the assured the unearned premium pro rata; but the company, hall first retain not less than dollars ($ ), it being understood and agreed that this sum shall de the minimum earned premium under this policy.

E. This policy may be canceled by the company at any time by notice in writing to the assured. It Day also be canceled by the assured, by like notice in writing to the company, 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. It canceled on 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 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 wages expended to the date of cancellation. In any case the minimum earned premium stated in clause D shall be retained by the company. If canceled for non-payment of premium, the earned premium shall be computed at short rates on the basis of the premium stated in the poliey and for the time the policy has been in force.

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 employees; and the assured shall, whenever 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. The company, or any of its inspectors, shall have the right and opportunity at all reasonable times to inspect the plant, works, machinery and appliances used in the business ; and may, by written notice, suspend this insurance until any defects or dangerous conditions are remedied to the satisfaction of the company. For the period of suspension the company will pay a pro rata return premium.

G. 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, or in connection with wrecking or suffered by any person before the premises are ready for occupancy. Ordinary repairs only, when made by employees whose wages are included in the estimated payroll are permitted, including care, custody and maintenance of premises and plant.

General Agreements and Schedule same as on Employers' Liability Policy.

EMPLOYERS' LIABILITY POLICY OF THE PACIFIC COAST

CASUALTY COMPANY OF CALIFORNIA. In consideration of dollars ($ ) premium, and of the statements contained in the schedule hereto attached and made a part hereof, which statements form the basis of this contract, and which statements the assured warrants to be true, the Pacific Coast Casualty Company (hereinafter called the company) does hereby agree to idemnify of

, County of State of (hereinafter called the assured), for the term of months, beginning on the day of

, 190 , at noon, 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 conditions precedent: 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.

SPECIAL AGREEMENTS. A. The company's liability for an accident resulting in injuries to, or in the death of one person, is

dollars ($ .), and, subject to the same limit for each person, is limited to dollars ($ for an accident resulting in injuries to or in the death of more than one person.

B. This policy does not cover loss from liability for injuries as aforesaid caused by or happening in or about any elevator plant, nor 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 the 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 conDection with wrecking. Ordinary repairs when made by employees whose wages are included in the estimated pay-roll are permitted.

D. The premium is based on the compensation to employees expended by the assured during the period of this policy. It the compensation expended exceeds the sum stated in the schedule hereinafter given, the assured shall pay the additional premium earned; if less than the sum stated, the company will return to the assured the unearned premium, pro rata; but the company shall, in any event, retain as compensation the sum stated in the schedule hereon as the minimum premium for this policy.

limited to

E. This policy may be canceled by the company at any time by notice in writing to the assured, statiing when the cancellation shall be effective. It may also be canceled by the assured by notice in writing to the company, 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 polícy shall have been in force. If canceled on the company's motion, the company shall pay or tender to the assured the unearned premium, pro rata. The company's check, mailed to the address of the assured, as given herein, shall be sufficient payment or tender of pay. ment; but no return premium shall be payable until the assured shall have rendered to the company a full statement of compensation to employees expended to the date of cancellation. If canceled at request of the assured, the company shall retain the customary short-rate premium. In any case, the minimum premium stated in the schedule hereon 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 the employees covered by this policy, and to inspect the plant, works, machinery, and appliances used in the business of the assured covered by this policy. The assured shall, if requested, furnish the company with a written statement of the amount of compensation paid to the employees covered by this policy during any part of the policy period, and under oath, if required.

GENERAL AGREEMENTS. (First.) The assured, upon the occurrence of an accident, shall give immediate written notice thereof, with fullest particulars obtainable, to the home office of the company, or to its duly authorized agent in the locality in which this policy is issued. 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.

(Second.). If thereafter any action is brought against the assured to enforce a claim for damages on account of said accident, the assured shall immediately forward to the home office of the company, or to its duly authorized agent in the locality in which this policy is issued, 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 against such action in the name and on behalf of the assured, or settle the same, unless it shall elect to pay to the assured the indemnity provided for in clause "A" of special agreements as limited therein.

(Third.) The assured shall not settle any claim except at his own cost, nor incur any expense, nor interfere in any negotiation or legal proceeding without the written consent of the company, but he may provide at the time of the accident such immediate surgical relief as is imperative. The assured, when requested by the company, shall aid in sccuring information, evidence and the attendance of witnesses, and in effecting 'settlements, and in conducting a defense and prosecuting an appeal. In case the company calls for the attendance of any employee or employees, as witnesses at inquests or ia suits, the assured wiú secure his or their attendance, making no charge for his or their loss of time.

(Fourth.) This policy does not cover loss from liability for injuries to, or caused wholly or in part by any child employed 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.

(Fifth.) 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 this company a larger proportion of the loss than the sum hereby insured bears to the whole amount of insurance. If the assured has any other policy in this company covering a claim for injury which might also be covered by this policy, the assured shall élect the policy under wbich all claims for said injury shall be treated, but the company shall not be beld responsible for a liability under more than one policy.

(Sixth.). Any assignment of interest under this policy shall be void unless the written consent of the company is indorsed hereon by one of its officers.

(Seventh.) No action shall lie against the company for any loss under this policy, unless it shall be brought by the assured to reimburse him 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 expiration of such period there is pending an action against the assured, brought by said claimant; in which case an action may be brought against the company by the assured within sixty days after final judgment therein has been rendered against and satisfied by the assured. The company does not prejudice nor waive by this clause any defenses which it may be entitled to make under this policy.

(Eighth.) In case of payment of loss under this policy, the company shall be subrogated to all claims or rights 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 the said rights.

(Ninth.) 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, nor shall notice to any agent, nor shall knowledge poesessed by any agent or any other person, be held to effect a waiver or change in this contract or any part of it.

(Tenth.) In any matter relating to this insurance, no person, unless duly authorized in writing, shall b: deemed the agent of the company.

SCHEDULE. 1. Name of assured 2. Address of assured (name, street, town, county and State where office is located) 3. The trade or business of the assured is 4. The factories, shops, or yards are located as stated below. The trade or business carried on at each such location, and the number of employees and the pay-roll at each such location, are as follows:

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9. The

5. The operations carried on are those usual and necessary to the trade or kind of business described above.
5. No power, explosives or chemicals are used except as follows: 7. There are no elevators on the
premises except as follows: 8. There are no boilers on the premļses except as follows:
estimated pay-roll includes the wages of all executive officers, office men, piece workers employed on the
premises, and all other employees, except as follows: 10. The following similar insurance is carried
and will be carried during the term of this policy: Employers' liability, $ Name of company
Boiler, $ Name of company Public liability, $. Name of company

Elevator, $
Name of company
Workmen's collective, $ Name of company

Teams, $ Name of company II. This risk has not been refused or cancelled by any company during the past three years except as follows: 12. The minimum premium for this policy is $

of

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, 190

EMPLOYERS' LIABILITY POLICY OF THE PENNSYLVANIA

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

, 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 , at noon, 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 co-ordinate, 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.

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 ($ 1.

B. This policy does not cover loss from liability for injuries as aforesaid caused by or happening in or about any elevator plant; nor 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 mentioned in the schedule, shall not be covered by this insurance, unless the number of drivers and helpers and their estimated wages are separately stated in the schedule, or they are drivers and helpers of teams for which the assured carries concurrent teams insurance in this company.

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 estimated 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 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 company will return to the assured the unearned premium, pro rata ; but the company shall first retain not less than

dollars ($ ), it being understood and agreed that this sum shall be the minimum earned 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 company, 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 such policy shall have been in force. If canceled on 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 cus. tomary 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 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, if 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.

G. In any matter relating to this insurance no person, unless duly authorized in writing, shall be deemed the agent of the company. Attached to and forming part of policy No. issued by The Pennsylvania Casualty Company to

Countersigned by

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, at Scranton, Pa., 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 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 against such proceedings in the name and on behalf of the assured, or settle the same, unless it shall elect to pay to the assured the indemnity provided for in clause A of special agreements as limited therein.

3. The assured shall not settle any claim except at bis 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 writing; but he may provide at the time of the accident such immediate surgical relief as is imperative. The assured when requested by the company shall aid in securing information, evidence and the attendance of witnesses and in effecting settlements and 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 nor cause wholly or in part by any child employed under tourteen 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 endorsed 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 him for loss actually sustained and paid by him in satisfaction of a 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 may 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 rights 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. 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 Pennsylvania Casualty Company of Scranton, Pa., has caused these presents to be signed by its president and secretary on the

day of

190 but the same shall not be binding on the company unless countersigned by a duly authorized agent.

SCHEDULE OF WARRANTIES. The said policy is to be based upon the following statement of facts which are warranted to be true and correct, and in consideration of which the policy is to be issued: 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 follows: (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 employees, 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 separately stated.)

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5. The operations carried on are those usual to the trade or kind of business described therein. 6. There are no 'steam-power boilers on the premises except as follows: 7. There are no passenger or freight elevators on the premises except as follows: 8. No power is used except as follows: 9. No chemicals are used except as follows: Io. No explosives are used except as follows: II. 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 payroll 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 executive officers, office employees, piece workers, and drivers and drivers' helpers, except as follows: 13. The following similar insurances are now carried: Employers' liability, $ ; name of company, Public liability, $ ; name of company,

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

Teams,

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