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Liberty <br />Northwest. <br />Member or Ubcrty Num! Group <br />Named insured <br />Coverage is Provided In: <br />Ohio Security Insurance Company <br />Common Policy Declarations <br />Agent <br />Policy Number: <br />BLS (14) 55 5119 80 <br />Policy Period: <br />From 07/15/2013 To 07/15/2014 <br />12:01 am Standard Time <br />at Insured Mailing Location <br />IRON CREEK CONSTRUCTION LLC <br />POLICY FORMS AND ENDORSEMENTS <br />(425) 455 -2227 <br />BORDELON INSURANCE <br />This section lists the Forms and Endorsements for your policy. Refer to these documents as needed for detailed <br />information concerning your coverage. <br />FORM NUMBER TITLE <br />CG 00 01 12 07 <br />CG 00 68 05 09 <br />CG 01 81 05 08 <br />CG 01 97 12 07 <br />CG 04 42 11 03 <br />CG 04 50 05 08 <br />CG 21 70 01 08 <br />CG 21 76 01 08 <br />CG 21 86 12 04 <br />CG21960305 <br />CG 22 79 07 98 <br />CG 24 26 07 04 <br />CG 26 77 12 04 <br />CG 83 20 12 08 <br />CG 84 94 12 08 <br />CG 84 99 08 09 <br />CG 85 83 10 09 <br />CG 88 10 10 09 <br />CG 88 65 12 08 <br />CG 88 70 12 08 <br />CG 88 77 12 08 <br />CG 89 27 10 09 <br />Commercial General Liability Coverage Form - Occurrence <br />Recording and Distribution of Material or Information in Violation of Law <br />Exclusion <br />Washington Changes <br />Washington Changes - Employment - Related Practices Exclusion <br />Stop Gap - Employers Liability Coverage Endorsement - Washington <br />Washington Changes - Who Is An Insured <br />Cap on Losses From Certified Acts of Terrorism <br />Exclusion of Punitive Damages Related to a Certified Act of Terrorism <br />Exclusion - Exterior Insulation and Finish Systems <br />Silica or Silica- Related Dust Exclusion <br />Exclusion - Contractors - Professional Liability <br />Amendment of Insured Contract Definition <br />Washington - Fungi or Bacteria Exclusion <br />Contractors Amendment of Pollution Exclusion (Job Sites) <br />Exclusion - Consolidated Insurance Programs Wrap -Up <br />Non - Cumulation Liability Limits Same Occurrence <br />Blanket Additional Insured Contractors - Products/Completed Operations <br />Commercial General Liability Extension <br />Voluntary Property Damage Extension <br />Construction Project(s) - General Aggregate Limit (Per Project) <br />Medical Expense At Your Request Endorsement <br />Washington Exclusion - Asbestos <br />In witness whereof, we have caused this policy to be signed by our authorized officers. <br />t -x'16( <br />Dexter Legg <br />Secretary <br />1 <br />Paul Condrin <br />President <br />To report a claim, call your Agent or 1 -800- 289 -0930 <br />DS 70 21 01 08 <br />07/12/13 55511980 1NWPBOR 235 NCAFPPNO INSURED COPY 001072 PAGE 14 OF 80 <br />