LIABILITY POLICY OF THE GENERAL ACCIDENT ASSURANCE CORPORATION, LIMITED, OF PERTH, SCOTLAND.

dollars ($

In consideration of the warranties hereinafter set forth and of premium, The General Accident Assurance Corporation, Limited (hereinafter called the corporation), does hereby agree to indemnify

190 at noon, and ending on the

of

County of State of months, beginning on the 190 at noon,

day of

(hereinafter called the assured), for the period of day of Standard time, at the place where this policy has been countersigned, subject to the follow. ing special and general agreements which are to be construed as co-ordinate, as conditions:

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 United States Managers, at the office of the corporation, in Philadelphia, Pa., or to the 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 all times render to the corporation all co-operation and assistancen 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 United States Managers, at the office of the corporation, in Philadelphia, Pa., every summons or other process as soon as the same shall have been served on him, and the corporation will defend against such proceedings in the name and on behalf of the assured, or settle the same, assuming costs incident to the conduct of such defense or negotiations for settlement, 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 his own cost, nor incur any expense, nor interfere in any negotiation for settlement or in any legal proceeding, without the consent of the corporation 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 corporation shall aid in securing information, evidence and the attendance of witnesses, and in effecting 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 corporation 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 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.

6. No assignment of interest under this policy shall bind the corporation unless the written consent of the corporation is endorsed hereon by the United States managers.

7. No action shall lie against the corporation 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 shail 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 corporation by the assured within sixty days after final judgment has been rendered and satisfied as above. The corporation 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 corporation 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 corporation 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 the United States managers, 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 General Accident Assurance Corporation, Limited, by its United States managers, has executed and attested these presents this day of 190 This policy shall not be valid until countersigned by the duly authorized representative of the corporaUnited States managers.

tion at

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 corporation'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 or 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 excluded from this insurance, provided the number of drivers and their estimated wages are separately stated in the estimated pay-roll or they are drivers of teams for which the assured carries concurrent teams' insurance in this corporation.

C. 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 dollars ($ ), it being understood and agreed that this sum shall be the minimum earned premium under this policy.

than

D. 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 canceled 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 expend ture 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 C shall be retained by the corporation.

E. 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 emp oyees, and also to inspect the plant, works, machinery and appliances used in his business. The assured shall, 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.

F. 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. Ordinary repairs when made by employees whose wages are included in the estimated pay-roll are permitted.

G. In any matter relating to this insurance no person, unless duly authorized in writing, shall be deemed the agent of this corporation.

H. The statements contained in the schedule hereinafter given are hereby made a part of this contract, which statements the assured makes on the acceptance of this policy and warrants to be true, saving as to matters which are declared to be matters of estimate only.

1. Name of assured

SCHEDULE.

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 location, and the number of employees and the pay-roll at each location are also fully stated below.

Estimated Estimated TRADE OR KIND OF BUSINESS. LOCATION OF PLANT. AV. Number Pay-Roll for of Employees. Policy Term.

Premium

Rate per $100 Amount of Premium. of Wages.

Enter in "trade or kind of business," 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. Drivers and drivers' helpers may be covered under Employers' Liability Form if wages are separately stated. Do not include drivers' pay-roll in daily report for Public Liability Form (see clause "B" Special Agreements).

II.

5. The operations carried on are those usual to the trade or kind of business described above. 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: 10. No explosives are used except as follows: 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 above 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 on the premises, including executive officers, office men, piece workers and drivers and drivers' helpers, except as follows: 13. The following similar insurances are now carried: Name of company Employers' Liability, $ ; Public Liability, $ ; Elevator Liability, $ Teams' Liability, $ ; Workmen's Collective, $ ; Boiler, $ 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: total expenditure for wages for the last calendar year (ended December 31, 190 ) was $ minimum premium for this policy is $

16. The

17. The

EMPLOYERS' LIABILITY POLICY OF THE AMERICAN FIDELITY COMPANY OF MONTPELIER, VERMONT.

In consideration of dollars premium and the statements and agreements set forth in the application for this policy, all of which statements and agreements the insured by the acceptance of this policy warrants to be true, and which application is made a part hereof, hereby insures State of for the term of at noon, standard time at the place

months expiring on the

of
day of

county of

190

where this policy is countersigned and subject to the provisions and agreements herein contained and endorsed hereon, as follows:

Against loss from common law or statutory liability for damages for bodily injuries, fatal or non-fatal, accidentally suffered within the period of this policy by any employee or employees of the insured while on duty within the factory, shop, or yards described in the schedule hereinafter set forth, or upon the ways immediately adjacent thereto provided for the use of such employees, 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.

B. This insurance shall cover drivers and drivers' helpers while on duty in the employ of the insured at places other than those mentioned in the schedule, provided they are enumerated in said schedule and pay-roll.

C. This policy does not cover liability for injuries as aforesaid caused by or happening in or about any elevator plant, or caused by the explosion, collapse or rupture of any steam boiler, unless such elevator plant and such boiler are enumerated in the schedule hereinafter set forth; 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; nor for injuries to any child employed contrary to law, or under fourteen years of age where no statute restricts the age of employment; nor for injuries in connection with wrecking; nor 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 insured; but 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 insured during the period of this policy. If the compensation actually paid exceeds the sum stated in the schedule hereinafter set forth, the insured shall pay the additional premium earned; if less than the sum stated, the company will return to the insured 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 giving five days' notice thereof in writing to the insured stating specifically when the cancellation shall be effective. It may also be canceled by the insured 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. If canceled by the company the company shall pay or tender to the insured the unearned premium, pro rata, when determined. If canceled at the request of the insured the company shall retain the customary short-rate premium and return the balance, if any, to the insured when determined. The check of the company mailed to the address of the insured as given herein shall be a sufficient tender; but the return premium shall not be payable until the insured shall have rendered to the company a full statement of wages expended to the date of cancellation. F. The company shall have the right and opportunity at all reasonable times to examine the books of the insured 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 insured shall, if requested, furnish the company with a written statement under oath of the amount of such compensation during any part of the policy period.

GENERAL AGREEMENTS.

1. The insured, upon the event of an accident, shall give immediate notice thereof in writing, with full particulars to the home office of the company, or to its duly authorized agent. He shall give like notices, with full particulars, of any claim which may be made on account of such accidant.

2. If any suit is brought against the insured to enforce a claim for damages for an accident covered by this policy, the insured shall immediately forward to 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 insured, or settle the same, unless it shall elect to pay to the insured the indemnity provided for in clause "A" of special agreements as limited therein.

3. The insured may at his own expense be represented by counsel, but he shall not settle any claim, except at his own cost, nor incur any expense nor interfere in any negotiations for settlement or in any legal proceeding without the consent of the company previously given in writing. He may provide at the time of an accident such immediate surgical relief as is imperative, and when requested by the company, shall aid in securing information, evidence and the attendance of witnesses and in effecting settlements.

4. If the insured carry the 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 insured has any other policy in this company, in respect of any injury covered hereby, he shall elect the policy under which claim is made; but the company shall not be held responsible for liability under more than one policy.

5. Any assignment of interest under this policy shall be void, unless the written consent of the company is endorsed hereon by the secretary.

6. No action shall lie against the company under this policy unless it shall be brought by the insured to reimburse him for loss actually sustained and paid by him in money in satisfaction of a judgment after trial of the issue. No such action shall lie unless brought within the period within which a claimant might sue the insured for damages, but if at the expiration of such period there is an action pending against the insured, then in such case an action may be brought against the company by the insured within ninety days after final judgment has been rendered and satisfied as above, and not afterwards.

7. In case of payment of loss under this policy, the company shall be subrogated to all rights of the insured in respect of such loss against any person or persons, and the insured shall execute any and all papers required to secure to the company said rights.

8. An agent has no authority to change this policy or to waive any of its provisions or agreements, nOT 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 in any part of it. No change whatever in this policy nor waiver of any of its provisions or agreements shall be valid unless an endorsement is made hereon, signed by the secretary of the company, expressing such waiver or change.

2. Of

county of

SCHEDULE.

State of 3. The insured is

1. Name (State whether individual, co-partnership, corporation or estate.) 4. Please give special attention to the following schedule, and answer fully and concisely.

5. No power is used except as follows: (Electric, water or steam. If boilers, how many and their uses.) 6. There are no passenger or freight elevators on the premises except as follows: 7. No chemicals are used except as follows: 8. No explosives are used except as follows: 9. 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, the number of employees, and the pay-roll on such presses.) 10. The pay-roll covers the wages of all employees, officers, office men, piece workers, drivers and drivers' helpers, except as follows: II. Other insurances carried are: Employers' liability, $ company, Public liability, $ ; name of company, Elevator, $ ; name of company, Teams, $ ; name of company, Workmen's collective, $ ; name of company. Boiler, $ ; name of company. 12. Insurance, in amounts stated in warranty II, will be carried during the term of this policy, except as follows: 13. This risk has not been refused or canceled by any company during the past three years except as follows: 14. Total wages for the last calendar year ending December 31, Minimum premium for this policy is $

$

; name of

EMPLOYERS' LIABILITY POLICY OF CASUATLY COMPANY OF

AMERICA.

In consideration of the warranties made in the application for this policy and of dollars, the Casualty Company of America, a New York corporation, hereinafter called the company," does hereby agree to indemnify , hereinafter called the "assured," of for the period of months, beginning on the

State of

county of day of 190 at 12 o'clock, noon, and ending on the day of 190, at 12 o'clock, noon, standard time, at the place where this policy is countersigned, subject to the accompanying general and special 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 during the term of this policy by any employee or employees of the assured, while 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, in and during the operation of the trade or business described in 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 ($ J. B. This policy does not cover loss from liability for injuries, as aforesaid, to or caused by any person

unless his compensation is included in the estimate hereinafter set forth and he is injured in an occupation hereinafter described; 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.

C. The premium is based on the compensation to employees to be expended by the assured during the period of this policy. Whenever employees are compensated in whole or in part by store certificates, board, merchandise, credits or any other substitute for cash, the amount of compensation covered by such substitutes shall be included in the pay roll. At the end of the policy period, the assured shall report to the company the actual compensation paid to employees. If the compensation actually paid exceeds the sum named 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.

D. This policy may be canceled by the company at any time by notice in writing to the assured. 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 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 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 C 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 premium stated in policy and for the time the policy has been in force.

E. 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, it 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 this business; and may, by written notice, suspend this insurance, until 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.

F. 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 pay roll, are permitted, including care, custody and maintenance of premises and plant.

GENERAL AGREEMENTS.

1. The assured, upon the occurrence of a casualty covered hereby, shall give immediate written notice thereof, with the fullest information obtainable at the time, to the company's duly authorized local agent or to its home office in New York city; and shall also give immediate written notice, with full particulars, of any and all claims which shall be made on account of a casualty covered hereby; and shall at all times render to the company all possible co-operation and assistance.

2. If thereafter any suit be brought against the assured to enforce a claim for damages on account of any casualty covered hereby, the assured shall cause every summons, process and other paper relating to such suit to be delivered to the company as soon as served on the assured. Upon and after the receipt of such summons or process the company wiil, at its own cost, defend the suit in the name and on behalf of the assured or settle the same. The company shall not incur hereunder any liability to the assured for a casualty upon which suit has been brought, unless the assured shall have afforded to the company, as herein before provided, opportunity to defend such suit.

3. The company, upon notice and request of the assured, will also provide at the company's expense counsel to represent and defend any and all employees of the assured who may have been subjected to arrest by reason of any casualty for which the company may be liable to the assured hereunder; but this obligation shall not apply save to preliminary hearings cr examinations before a magistrate or coroner in the State of New York and to those preliminary hearings or examinations in other States corresponding

thereto.

4. The assured shall not interfere in any legal proceedings relative to or growing out of any casualty covered in whole or in part hereby, nor with negotiations for the settlement of any claim arising from such a casualty, nor settle any such claim save at the cost of the assured, nor incur any expense in connection with such casualty save such as may be necessary in providing at the time of an accident imperatively needful surgical relief; but the assured, if and whenever requested by the company, shall aid it in procuring information, evidence and the attendance of witnesses, in effecting settlements and in presecuting appeals. 5. The company shall not be liable under this policy unless an action to enforce such liability be brought within sixty days from the date of the entry of a final judgment against the assured, after a trial of the issues on the merits, in a suit duly instituted within the period limited by the statute of limitations, awarding damages on account of a casualty covered hereby; and then only provided that such action against the company be brought by the assured personally, for damages sustained by the assured in paying and satisfying such final judgment. This clause shall not in any way limit, restrict or abridge the company's defenses to any such action.

6. In case of the payment of a loss under this policy, the company shall be subrogated to all claims and rights of the assured against any person or persons in respect to such loss, and to all judgments and decrees establishing such claims or rights; and the assured shall execute and deliver to the company any and all papers required by it to secure to it the said claims and rights and shall co-operate with the company to enforce the same.

7. This policy does not cover any loss from liability for injuries to, or caused wholly or in part by, any person employed by the assured, if the employment be contrary to law, or if such person, in the event that there be no statute fixing the minimum age at which a person may lawfully be so employed at the place where such injuries are received, be under the age of fourteen years at the time of the casualty.

8. If the assured have other insurance (whether valid or not) against a casualty covered hereby, the assured shall not be entitled to receive from the company a larger proportion of the loss than the sum