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: 08/20/2019

THE FOLLOWING VEHICLES HAVE BEEN DELETED:

2002 INTERNATIONAL #7394 2002 INTERNATIONAL #7395 2002 INTERNATIONAL #7396 2002 INTERNATIONAL #7397

THE FOLLOWING VEHICLES HAVE BEEN ADDED:

2019 IC BUS VIN # 4DRBUC8N1LB828495 CLASS CODE 6184 COST NEW $91,469
2019 IC BUS VIN # 4DRBUC8N8LB828493 CLASS CODE 6184 COST NEW $91,269
2019 IC BUS VIN # 4DRBUC8NXLB828494 CLASS CODE 6184 COST NEW $91,269
2019 IC BUS VIN # 4DRBUC8NXLB821979 CLASS CODE 6184 COST NEW $107,782
2019 IC BUS VIN # 4DRBUC8N4LB828491 CLASS CODE 6184 COST NEW $91,269
2019 IC BUS VIN # 4DRBUC8N6LB828492 CLASS CODE 6184 COST NEW $91,469

COVERAGES THAT APPLY:

LIABILITY	$1,000,000. MEDICAL PAYMENTS $5,000.
UNINSURED MOTORISTS $350,000.

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POLICY CHANGE ENDORSEMENT (continued)

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: 08/20/2019

UNDERINSURED MOTORISTS $350,000. COMPREHENSIVE $1,000 DEDUCTIBLE COLLISION $1,000 DEDUCTIBLE

VEHICLE IDENTIFICATION CARD(S) ATTACHED.

Original Annual Premium

New Annualized Premium

$	30,650.00

$	32,289.00	TOTAL ADDITIONAL PREMIUM	$	1,415.00

Countersigned:	By	

Authorized Representative	Date

Date Issued: 08/22/2019

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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: 08/20/2019

Premium for this Transaction:	$	1,415.00

STATEMENT OF ACCOUNT

Acct Date

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

Premium

$	7,662.50 $                185.75 $	8,072.25 $	8,072.25
$	8,072.25

Commission Percent

10.00% 10.00% 10.00% 10.00%
10.00%

Surcharge/ Assessment

$	0.00 $	0.00 $	0.00 $	0.00
$	0.00

Commission Percent

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

Total Due

7,662.50 185.75 8,072.25 8,072.25
8,072.25

Total Premium Charged: $	32,065.00

Date Issued: 08/22/2019

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