ENDORSEMENT

	

Policy Number: BA 9733247
	
Prior Policy: 9733247

Billing Type: AGENCY BILL

Coverage Is Provided In THE NETHERLANDS INSURANCE COMPANY-A STOCK COMPANY

Named Insured and Mailing Address:
INDIAN HILL EXEMPTED VILLAGE SCHOOL DISTRICT
6855 DRAKE ROAD CINCINNATI OH 45243
	
Agent:
CIC/LICKDYKE INSURANCE AGENCY 1060 NIMITZVIEW DR STE 120 CINCINNATI OH 45230-4351

Agent Code: 0021251	Agent Phone: (513)-684-7900

POLICY CHANGE ENDORSEMENT

POLICY PERIOD: From: 06/30/2019	To: 06/30/2020	at 12:01 AM Standard Time at your mailing address shown above.

DESCRIPTION OF CHANGE	CHANGE EFFECTIVE DATE: 11/14/2019

THE FOLLOWING VEHICLE IS ADDED:

VEH 50, 2017 FORD T-250 VAN	VIN #1FTYR3XM9HKA11615 CLASS 6181 / COST NEW $49,923

LIABILITY:

UM/UIM:

$1,000,000

$ 350,000

MEDICAL PAYMENTS: $ 5,000 COMPREHENSIVE:	$ 1,000 DED COLLISION:	$ 1,000 DED

VEHICLE IDENTIFICATION CARDS ATTACHED

Original Annual Premium

New Annualized Premium

$	32,289.00

$	32,795.00	TOTAL ADDITIONAL PREMIUM	$	317.00

Countersigned:	By	

Authorized Representative	Date

Date Issued: 11/19/2019

17-60 (10/94)

06/30/2019	9733247

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Policy Number: BA	9733247
	Prior Policy:	9733247
	
Policy Period:	06/30/2019	To: 06/30/2020	12:01 am Standard Time at the Mailing Address of the Named Insured
	
Coverage Is Provided In THE NETHERLANDS INSURANCE COMPANY-A STOCK COMPANY
	
Billing Type: AGENCY BILL	-	QUARTERLY
	
Named Insured and Mailing Address:
INDIAN HILL EXEMPTED VILLAGE SCHOOL DISTRICT
6855 DRAKE ROAD CINCINNATI OH	45243
	Agent:
CIC/LICKDYKE INSURANCE AGENCY 1060 NIMITZVIEW DR STE 120 CINCINNATI OH	45230-4351

Agent Code: 0021251	Agent Phone: (513)-684-7900

Reason for Amendment: ENDORSEMENT

Transaction Effective Date: 11/14/2019

Premium for this Transaction:	$	317.00

STATEMENT OF ACCOUNT

Acct Date

06/2019 08/2019 09/2019 11/2019 12/2019
03/2020

Premium

$	7,662.50 $	1,415.00 $	7,662.50 $                   64.00 $	7,789.00
$	7,789.00

Commission Percent

10.00% 10.00% 10.00% 10.00% 10.00%
10.00%

Surcharge/ Assessment

$	0.00 $	0.00 $	0.00 $	0.00 $	0.00
$	0.00

Commission Percent

0.00%	$ 0.00%	$ 0.00%	$ 0.00%	$ 0.00%	$
0.00%	$

Total Due

7,662.50 1,415.00 7,662.50 64.00 7,789.00
7,789.00

Total Premium Charged: $	32,382.00

Date Issued: 11/19/2019

17-80 (04/97)

06/30/2019	9733247

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