Free Other Notice - District Court of Arizona - Arizona

CASE NO. CIV-04-0662-PIIX-DGC I
U-IIAUL IN'I`IiRNATIONAL , IiT AL 1
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xx LUN/IBIERNIIENS MUTUAL CAS. CO. 1
I°I,AINTIFF`S EXHIBIT ¤ 7
~ DATE IDIiN. I
I DATE: Ii\1’ID,
? BYQ, W, , , elf! /. V,
Deputy Clerk
Case 2:04-cv-00662-DGC Document 191-3 Filed 06/O1/2007 Page 1 013

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CHECK IF APPROPRIATE COVERAGE EXPO$L,RE COVERAGE EXVJSLYE
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cument 191-3 Filed 06/O1/2007 Page 2 013
Case 2·O4-cv—OO662-DGC DO

CARE, CIJS`I’OD'r', CONTROL g
LOC .,:Q°., Q”Q,;Z‘, VALLI A' ¤· L· ’.>· SQ FTIBLOC OCC 0c:LI¤ANCYI¤;scR.P*TtcN :>F¤Er ' APPLICANT [AQ S HELD HARMLESS IN TONE LEASE. 'B MAS A WAIVER OF SLBROCATTON [CI IS A NAMED INSLRED 'N "'~E EERE POLICY. fDf OTHER isccccfyj
ADDITIONAL EXPOSURES
EXPLALN ALL ‘YES' RESPONSES. PROVOE OTHER INFORMATION RLOLTRSD YB NO EXPLAIN ALL `YY.S' RESPONSES. PROVIDE OTHER INYORAIATION REOLTRED YES
ADVERTTSEPCS LIABILJTY POLLUTION LIABILITY EPA4:
I MEDIA USED, YEL;,OW PAGES ANNUAL COST SZECCCCOC 20 OO CCRFGNT OR PAST PRODUCTS OR THEIR CDMPON ENTS
Z SERVICES O; AN ADVER—mSII,G AGENCY usyy V CONTAIN HAZARDOUS MATERIALS THAT MAY REQUIRE
J ANY covsmcs PROVIDED UNDER AGENCYZS PCLICY` II SPECIAL DISPOSAL METHOD?
Ar¤¤zAn· 1_;A¤|I_;7y _ Z! INDICATETHECOVERAGES CARRIED
4 DOES APPLICANT OWN / LEASE / OFERAE AIRCRAFT { Y . X GL WITH STANDARD ISO PCLLLQTTON EXCLLSION
AUTO LIABILITY CLWITH STANDARD SLDDENISL ACCIOENTAL ONLY
5 ARE EXPLOSIVES. CALQSTTCS. FL.AN1MABLE.S OR OTHER GL, WITH PCLLQTTON COVERAGE ENDCRSEMENT
DANGEROUS CARGO HAULEDR *4 SEPARATE POLLLTTON COVERAGE
6 ARE PASSENGERS CARRIED FOR A FE? V PRODUCT LIABILJTY
7 ANY UNITS NOT INSURED BY LNOERLYING POLICZEF N 22 ARE MISSLES. ENGINE GLJIDANCESYSTEMS, FRAMES OR ANY
s ARE ANY VEHICLES LEAsa¤ OR RENTED TO 07*11am* * OTHER PRODLU USEDI I‘~$TAL¢ii> iN A·R€?~A¤`
9 IS HIRED AND NONIOWNED COVERAGE PROVIDEDR * LE ARE FOREIGN PRODUCTS OISTRIBDTED ZN L S.?
Y "0Nr¤A¤0u LIABILITY I Z4 ARE L S. PROOLCTS SOLO OR DLSTRIBLTED EN FORELGN COLNTRIET I
I IS BRIDGE. DAM. OR MARINE WORK PERFCRMEY M I25 FRODLC7 LABILITY LOSS ZN PAST} YEARS? ’SFEC§F”T
6 IESCRIBE TYPICAL JOBS PERFORMED IATACF SE?ARA"E SHEETS 26 GROSS SALES FROM EACN OF LAST} YEARS
A/A I S TZSCCCCCCC S T47‘952CCC I ‘C'5LCC`.CCC
YRO'T`E(7`IV`E LIABILITY
E2 DESCRZBE AGREEMENT [ATTACH SEPARATE 27 DESCRIBE INDEPENDENT CONTRACTORS
N/A SLJBS LISED IN BLOGS, RENCVATNC.
· S`ORAC2E FACZLZYES, NCVZNG
.3 DOE APFL.CANTOWN_ RENT ORCTHERWLSE LSECRANE" N
I4 DO SIJBCONTRACTORS CARRY COVERAGES XT
OR LIMITS LESS TTIAN APPLICANT N IvA*r:RC¤.,I¤ LIABILITX I
EMPLOYEE LIABILITI is DOES AP¤L.CANT OWN OR LEASE ‘»>·’ATERCRAP` ` I
I5 IS APPLJCANTSELF-INSLREO IN ANY STAT? N I GMES ~»5>·¤"~ ~¤¤55?'J*5* K!
I6 SUBJECT TO JONE: AC Faq X raven ' ’
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INCIDENTAL HALPRACTTCE LIABILITY APARTXIENTS ~' CONDCMINILWIS I IIOTELJI ‘\I(7TEL5
.7 HOSPITAL OR FIRST AIO FACZLJTV MA.NTA,NE;>° N I 5*:;¤.$; 1 LNITE rswrvu NC =>0<;1; I ¤··~*‘NC BOARDS V
.8 COVERAGE PROVIDED ECR DOCTORSINLRSESI N II/;,
.9 INDICATEIOF DOCTORS NURSES BEDS `
REMARKS VEHICLES
NISCELLANEOLS INFORMATION Tw; »uwN5¤ -I¤~4;1v-1;;n1 L;A5;¤ r¤0rssw~><.L.,;; wow. $0—1mNI gov?
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TNIE STATEMENTS 'ANSWERSI GIVEN ABOVE ARE TRUE AND ACCLRATE. THE APPLICANT HAS NOT I
W’LL.FULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCE CONCERNING
T··II:; APFLRCATTON. THIS RPULICATTON DOES NOT CCNSTTTLTE A BINDER
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1 191-3 Filed 06/O1/2007 Page 3 of 3
. _ - 662-DGC Documen
Case 2.04 cv OO

Case 2:04-cv-00662-DGC

Document 191-3

Filed 06/01/2007

Page 1 of 3

Case 2:04-cv-00662-DGC

Document 191-3

Filed 06/01/2007

Page 2 of 3

Case 2:04-cv-00662-DGC

Document 191-3

Filed 06/01/2007

Page 3 of 3