$

; 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 company during the past three years except as follows:

Name of Company.

Reason.

From

Term Carried.

To

$

.

16. The total expenditure for wages for the last calendar year (ended December 31, I The minimum premium for this policy is $ time, at the place where the policy is countersigned,

day of

, 190

,) was The risk to commence at noon, standard , 190 Dated

EMPLOYERS' LIABILITY POLICY OF THE TRAVELERS INSURANCE COMPANY OF HARTFORD, CONNECTICUT,

(called the company), in consideration of the warranties of the assured hereinafter expressed and of dollars ($ ) advance premium, does hereby agree to indemnify of county of State of (called the assured) against loss by reason of the liability imposed by law upon the assured for damages on account of bodily injuries, including death resulting therefrom, accidentally suffered by reason of the operation of the business herein stated by any person or persons employed by him, and while within the factories, shops, or yards herein described, or upon the ways immediately adjacent thereto provided for the use of such employees; provided such bodily injuries are suffered 190, at noon, and ending on 190, at noon, standard time, at the assured's address above stated. Drivers and drivers' helpers, if hereinafter specifically enumeruted, while so employed outside such factories, shops, or yards, shall also be covered by this policy. This insurance is subject to the following conditions:

within the period of the day of

beginning on the

day of

A. The company's liability on account of an accident resulting in such injuries to one person (including death) is limited to dollars and, subject to that limit for each person, the company's total liability on account of any one accident resulting in such injuries to more than one person (including deaths) is limited dollars.

to

B. This policy does not cover loss from liability on account of such injuries (including death) caused or suffered by (a) any convict labor; (b) any person employed in violation of law as to age, or under the age of fourteen years where there is no legal age limit; (c) any person whose compensation is not included in the estimated compensation hereinafter set forth, except drivers who are specifically enumerated in any concurrent teams policy carried by the assured with this company; (d) any person by reason of making additions to, alterations in, or the construction, demolition, or extraordinary repair of any building, structure, or plant, unless a written permit describing the work to be undertaken is signed by an officer of the company and hereto attached. (Ordinary repairs, including renewal of existing mechanical equipment, may be made on the premises hereinafter described by employees whose compensation is included in the estimated pay roll, without such perinit.)

C. The premium is based upon the entire compensation earned by all employees of the assured, not herein elsewhere specifically excluded, engaged in the operation of the business herein stated during the period of this policy, the amount of such compensation to be stated by the assured to the company at the end of such period, and the earned premium adjusted in accordance therewith at the rates hereinafter specified. If the earned premium thus computed is greater than the advancé premium paid, the assured shall immediately pay the additional amount to the company; if less, the company shall return to the dollars, agreed to be the minimum premium

assured the unearned portion, but a sum not less than hereon, shall be retained by the company in any event. D. This policy may be canceled at any time by either of the parties upon written notice to the other party stating when thereafter cancellation shall be effective. The date of cancellation shall then be the end of the policy period and the earned premium shall be computed and adjusted as provided in paragraph C. lf, nowever, such cancellation is at request of the assured and he is not retiring from the business herein described, the compensation for the full original policy period shall be computed upon the basis of the compensation to date of cancellation and the customary short rate premium charged thereon. Notice of cancellation mailed to the address of the assured herein given shall be a sufficient notice, and the check of the company similarly mailed a sufficient tender of any unearned premium.

E. The company shall be permitted, when it so desires, to examine the books of the assured so far as they relate to the compensation of his employees, and to inspect the plant, works, machinery and appliances used in his business.

F. The assured, upon the occurrence of an accident, shall give immediate written notice thereof, to the company or to its duly authorized agent, with the fullest information obtainable. He shall give like notice, with full particulars, of any claim made on account of such accident, and if thereafter any suit, even if groundless, is brought against the assured to recover damages on account of such injuries as are covered by this policy, the assured shall immediately forward to the company every summons or other process served on him, and the company will, at its own cost, defend against such suit 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 paragraph A.

G. The assured shall not voluntarily assume any liability or settle any claim except at his own cost, nor incur any expense, nor interfere in any negotiation for settlement or 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 effecting settlements, securing evidence, the attendance of witnesses, and in prosecuting appeals.

H. If the assured carry a policy of another insurer, whether valid or not, against a claim arising under this policy, he shall not recover from the company a larger proportion of the loss than the sum hereby insured bears to the whole amount of the insurance.

I. No assignment of interest under this policy shall bind the company unless the written consent of the company is endorsed hereon by one of its officers.

J. No action shall lie against the company to recover for any loss under this policy unless it shall be brought by the assured himself for loss actually sustained and paid in money by him in satisfaction of a judgment after trial of the issue; nor unless such action is brought within ninety days after final judgment against him has been satisfied.

K. The company shall be subrogated, in case of payment of loss under this policy, to the extent of such payment, to all rights of recovery for such loss by the assured against persons, corporations, or estates. L. No condition or provision of this policy shall be waived or altered except by written endorsement attached hereto and signed by the president, a vice-president, secretary, or assistant secretary of the company; 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 any part of this contract. The personal pronoun herein used to refer to the assured shall apply regardless of number or gender,

M. The following declarations, numbered one to fifteen inclusive, are warranted by assured to be true, the estimated average number of employees and estimated total annual compensation only excepted.

1. Name of assured

DECLARATIONS.

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. A full classified description of the business operations to be insured, the estimated average number of employees to be engaged in each classification, the estimated total annual compensation of such employees in each classification, the premium rate to be paid thereon, and the locations of all factories, shops and yards where such operations are conducted are given in the following statement:

Classification of the Business
Operations to be Insured.

Estimated Average

Number
of Employees.

Estimated Total
Annual Wages Premium
and Other Rate.
Compensation.

Town. Street, and Number Where
Factories, Shops, and Yards
are Located.

5. The foregoing statement correctly describes the business operations to be insured and the following statement all unusual or special operations incident thereto. None of the special operations described below will be claimed as covered by the policy, unless the estimated average number of employees engaged in such special operation, their estimated total annual compensation, and the premium rate are specifically stated opposite the description of the operation to be covered, in the columns provided for that purpose.

6. The foregoing enumeration of employees includes all persons in the service of the assured, in con nection with the operations herein described, to whom eompensation of any nature is paid, saving only such exceptions as are noted specially below. The foregoing estimates of wages and other compensation are offered for the purpose of computing the advance premium. At the end of the policy period a statement, classified as above, of the actual amount of all such compensations earned while the policy was in force, whether paid or not, shall be rendered to the company and the actual earned premium computed thereon at the rates given in declarations 4 and 5 hereof. The company shall be permitted, when it so desires, to examine the books of the assured so far as they relate to the compensation of employees. Bodily injuries caused to or by any employee whose compensation is excluded from the foregoing statement shall not be covered by the policy. (N. B.-The wages of drivers who are specifically enumerated in concurrent teams policy carried by this company may be excluded.)

7. Pursuant to the above declaration the following employees are excluded from the estimates : 8. The employees to be covered by this policy do not make alterations in, extraordinary repairs or additions to, construct or demolish buildings or plant. (N. B.-Ordinary repairs, including renewal of existing mechanical equipment on the premises, when made by employees enumerated above, are to be permitted.) 9. The amount expended in wages and other compensation for twelve months ending 130, was $ II. No chemicals are used, except as follows: 12, No explosives are used, except as follows: 13. There are no elevators or hoisting devices so constructed that they cannot be stopped, started, and controlled by a person riding on same, except as follows: 14. Insurance will not be claimed except from , 190 at 12 o'clock, noon, 190 at 12 o'clock, noon. 15. The signature to the declarations for this policy is accepted by the assured as his signature. (Copy of signature to declarations.) Per

to

10. The power employed is

PHYSICIANS' LIABILITY POLICY.

The (hereinafter called the company), in consideration of the premium, and of the statements in the schedule hereinafter contained, which statements the assured makes on the acceptance of this policy and warrants to be true, does hereby insure the person described in said schedule for the period of one year from noon, standard time, of the day this contract is dated;

Against loss from common law or statutory liability for damages on account of bodily injuries, fatal or non-fatal, suffered by any person or persons, in consequence of any alleged error, mistake or malpractice made within the period of this policy by the assured in the practice of his profession as described in the schedule:

1. The company's liability for such damages on account of injuries to or the death of one person is limited to five thousand dollars ($5000), and subject to the same limit for each person, the total liability of the company under this policy for any number of persons not to exceed ten thousand dollars ($10,000).

2. The company shall not be liable under this policy if the assured shall have violated any law or ordinance in connection with any matter giving rise to any claim under this policy, nor if any alleged error, mistake or malpractice has happened while the assured is more or less under the influence of intoxicants, anæsthetics or narcotics.

3. The assured shall give immediate written notice of any claim against him for loss or damage arising under this policy, with the fullest information obtainable at the time, to the home office of the company at or to its duly authorized local agent, and shall at all times render to the company all co-operation and assistance in his power.

4. 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, at its own cost, defend against such proceeding in the name and on behalf of the assured.

5. The company will not compromise any claim without the consent of the assured. 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 proceedings, without the consent of the company previously given in writing; the assured when requested by the company shall aid in securing information, evidence, and the attendance of witnesses and in effecting settlements and in prosecuting appeals.

6. 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 such other policy.

7. No assignment of interest under this policy shall be valid unless the consent of the company thereto is formally endorsed hereon by an officer of the company.

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 ali papers required, and shall co-operate with the company to secure to it said rights.

9. Without prejudice to the rights of the assured as respects any error or mistake occurring during the period when the policy was in force, the company may cancel this policy at any time by written notice mailed to the address hereinafter given and the unearned portion of the premium shall be returned to the assured, and the company's check for such amount mailed with such notice shall be sufficient tender.

10. The company qualifies its agents by certificates countersigned by the superintendent of agencies. Persons not holding certificates shall not be deemed agents in any matter relating to this insurance.

II. An agent has no authority to change this policy or to waive any of its provisions, nor shall notice to any agent or knowledge of his or of any other person be held to effect a waiver or change in this contract or any part of it. No change whatever in this policy and no waiver of its provisions shall be valid unless an endorsement is added hereto signed by the president or one of the secretaries of the company expressing such change or waiver.

Schedule of warrauties made by

of

Schedule.

1. My residence

street, town of

county of

street, town of
in

State 3. My age 5. Since gradua

(all notices to be sent to above address) 2. My office is years. 4. I am a qualified physician and surgeon, graduated from tion I have practiced my profession in the following towns and cities 6. I have no physicians' and surgeons' liability insurance except as follows: 7. I am a memier in good standing of the following medical associations and societies 8. There is no suit pending against me for damages on account of alleged malpractice except as follows: No claim or claims have been paid by me nor has any judgment been entered against me for damages on account of malpractice except as follows: 10. I have no partner or partners, or employes who are in active practice, except as follows: (Give name.) (if insured, state name of company.) II. I am not employed by any firm or association except as herein stated (above schedule is part of this contract. See paragraph 11.) The premium is per annum. The date of this policy is

, 190

dollars

The

FLY-WHEEL POLICY.

(hereinafter called the company), in consideration of the warranties made in

the application for this policy, copy of which application is endorsed hereupon, and of dollars, does hereby insure

of

herein called the assured, for the term of

in the county of
and State of
months, beginning on the
day of

day of

, 19

19 at twelve o'clock noon, and ending on the at twelve o'clock noon, standard time, at place of explosion, in the principal sum of dollars; Against loss caused by the explosion, bursting or disruption, during rotation, of the flywheels or any of them scheduled in the application for this policy, as follows: A. For loss upon the fly-wheel or fly-wheels and upon other property of the assured. B. For loss from liability of the assured for loss upon property of any other person or persons. C. For loss from liability of the assured for bodily injuries or death sustained by any person or persons, but the company's liability for such injuries or death shall not exceed five thousand dollars for any one person injured or killed. D. The total liability of the company under this policy shall not exceed dollars ($ ), subject to the follow

ing agreements and conditions:

1. By "explosion, bursting, or disruption" shall be understood the sudden and violent tearing asunder of any part or parts of a fly-wheel caused by centrifugal force, or caused by stresses due to the transmission of power by the fly-wheel, or caused by the accidental breakage, derangement or displacement of any part or parts of an engine or other apparatus with which the fly-wheel may be directly or indirectly connected, or caused by something accidentally thrown into the fly-wheel. By "fly-wheel" shall be understood any balance wheel, belt wheel, rope wheel, gear wheel, pulley, or appliance which revolves about the axis of an engine shaft or shafts of any kind and which is scheduled in the application for this policy.

2. The company shall not be liable for loss under this policy unless the loss is caused immediately, solely and directly by the explosion, bursting or disruption, as above defined of the fly-wheels or any of them scheduled in the application for this policy. The company shall not be liable for loss due to stoppage of plant or work, nor for any other indirect loss caused by an explosion, bursting or disruption, including fire caused by an explosion, burstiag or disruption.

3. The company shall have the right at all reasonabie times to inspect the fly-wheels insured hereunder, and to examine any engine or other apparatus with which the fly-wheels may be directly or indirectly connected. Any inspector of the company is authorized to suspend the insurance under this policy, as respects any fly-wheel or fly-wheels, until defects or dangers reported by him are removed to the satisfaction of the company. Notice of such suspension and the reason therefor and of reinstatement must be in writing. The company will, on demand, pay to the assured a return premium for the period of suspension pro rata. 4. The company shall not be liable under this policy in case the engine governor is set to allow the flywheel to run at a speed in excess of the number of revolutions per minute scheduled in the application for this policy. The company reserves the right to change the authorized speed upon inspection, and notice of such change mailed by the company to the address of the assured as given above shall be sufficient.

5. The assured, upon the occurrence of an accident covered by this policy and also upon receiving information of a claim on account of an accident, shall give immediate notice in writing of such accident or claim with full particulars to the company, at its office in New York City, or to the agent, if any, who shall have countersigned this policy. If, thereafter, any legal proceedings are taken against the assured to enforce a claim for loss on account of such accident, the company will defend the same, at its own cost, in the name and on behalf of the assured.

6. In case of loss under this policy, the company, to the extent of its interest, shall be subrogated to all claims or rights of the assured as respects such loss against any third party or parties, and the assured shall execute all papers required to secure to the company said rights.

7. The company shall replace the damaged property of the assured, or pay for it in money. It shall first settle for direct property loss, or for the loss of property by others, or for personal injuries as the assured may elect. The assured shall not interfere in any negotiations for settlement with others, nor in any legal proceedings brought by others without the consent of the company. The assured shall render to the company reasonable assistance in securing information about losses and evidence in case of legal proceedings.

8. If the assured is covered, at the time of accident, by insurance granted by any other insurer against any loss covered by this policy, he shall be entitled to recover from this company its fair pro rata share of such loss. If the assured is so covered by other insurance granted by this company, the fact shall not affect his rights under this policy. Other insurance is permitted without notice, Notice of any assignment of this policy or of any interest under it must be given when made.

9. No agent has authority to change this policy or to waive any of its provisions nor shall any notice to any agent or knowledge of his or that of any other person, be held to affect a waiver or change in this contract, or in any part of it, unless an endorsement is added hereto, signed by the president or secretary of the company, expressing such waiver or change.

10. The statements made in the application endorsed hereupon are hereby made a part of this contract, which statements the assured makes on the acceptance of this policy and warrants to be true.

II. This policy may be cancelled by the company at five days' notice. In such case, the unearned premium, pro rata, less the cost of inspections already made, will be paid to the assured. It will be cancelled on the same notice at the request of the assured, provided he is retiring from business or suspending operations, and the return premium will be payable as above. The company's check, mailed to the address of the assured as given above, shall be a sufficient tender.

COPY OF APPLICATION.

Application is herery made by the subscriber for a Fly-Wheel Insurance Policy, to be based on the following statement of facts, and the schedule of fly-wheels given below, which are to be considered war

4. The engines whose fly-wheels are scheduled above are the only engines now operated at this plant 5. The engineer has no other duty than that of looking after the power plant 6. Other insurance carried is: Fly-wheel, $ , company, ; steam boiler, $ company, ; elevator, $ company, ; employers' liability, $ company, 7. Inspector's reports, and correspondence relating thereto, should be sent to the assured at the above address or to 8. There is no information tending to vary the risk, except as herein stated.

RESIDENCE BURGLARY POLICY.

dollars ($

(hereinafter called the company), in consideration of premium, and of the statements in the schedule hereinafter contained, which statements the assured makes on the acceptance of this policy and warrants to be true, and subject to the hereinafter special agreements as conditions, does hereby agree to indemnify of

assured), for the term of noon, and ending on the

county of

State of (hereinafter called the months, beginning on the day of , 190, at day of , 190 at noon, standard time, for direct loss by burglary, larceny or theft of any of the property described in the schedule hereinafter given and stated to be insured hereunder, occasioned by its felonious abstraction from within the house, building, apartments or rooms actually occupied by the assured and described in the said schedule, and hereinafter called the premises, by any person or persons employed by the assured or by any other person or persons lawfully or unlawfully in or upon the premises, and against direct loss by damage to the said property and to the said premises caused by any person or persons while unlawfully in or upon the premises with intent to commit burglary, larceny or theft.

SPECIAL AGREEMENTS.

A. The company's liability is limited to the sums attaching to the several items respectively of clause No. 9 of the schedule and subject to such limits as respects each item, the total liability hereunder is limited to the sum of dollars ($ ).

B. The company shall not be liable:-(1) For loss or damage if the property does not belong to the assured or to a member of his family residing with him, or to a person residing with or visiting the family who does not pay board or rent; (2) For loss of any precious stone or article of jewelry in excess of twenty-five per cent. of the amount of insurance under Item A of Clause 9 of the Schedule, unless such precious stone or article of jewelry is insured under item B of said clause, and in no event for loss of any precious stone or of any article of jewelry while the premises are left without an occupant; (3) For loss of sterling silverware, while the premises are left without an occupant, in amount exceeding ten per cent. of the amount of insurance attaching specifically under Item A of Clause 9 of the Schedule; (4) For money or securities of money, or for coin or stamp collections; (5) For any loss or for any damage which is in excess of the actual cash value of the property taken or damaged; (6) For loss or damage of any kind if the premises are left without an occupant for a period exceeding six consecutive months, unless the company's written consent for a further period of non-occupancy is endorsed upon or attached to the policy. C. If the assured is the occupant of an apartment in an apartment or flat house this insurance covers goods in a locked storeroom provided for the exclusive use of the assured by the landlord in the same house to the extent of fifty dollars and no more.

D. The company may repair any damages to property covered hereunder, and it may replace any damaged or lost article covered hereunder, with one of like quality and value, instead of paying for the same in money. When so replaced, the damaged or lost article shall belong to the company, but the assured shall be entitled to it upon payment to the company of the cost of its replacement or of the amount paid in money on account of its loss. If the assured has returned to him or recovers any article for the loss of which he has been indemnified, he shall report its recovery to the company immediately, and either repay to the company the amount of its loss thereupon, or forward such article to the company at its home office.

E. The premises will not be considered without an occupant" for the purposes of this policy unless the assured, all of the several members of his family and all of his several domestic servants are absent therefrom for at least seventy-two hours consecutively prior to the time of any loss.