Viewing page 45 of 59

This transcription has been completed. Contact us with corrections.

AUDIT

GENERAL ACCIDENT GROUP
1 GENERAL ACCIDENT FIRE & LIFE ASSURANCE CORP., LTD.
2 POTOMAC INSURANCE COMPANY
3 THE CAMDEN FIRE INSURANCE ASSOCIATION
9 PENNSYLVANIA GENERAL INSURANCE COMPANY

[[image]]

CB 2/26/68  ENTRY MONTH
POLICY NO  U 340761
AGENT  NEW YORK BR   SCHIFF TERHUNE
CO. NO.  1
AGENT'S CODE  67105
INSURED  JACQUES SELIGMANN & CO., INC.
AUDIT PEROID
FROM  12-31-66
TO  12-31-67
ADDRESS  5 EAST 57TH. ST. NEW YORK N.Y.
POLICY PERIOD
FROM  12-31-66
TO  12-31-67
LOCATION  AS ABOVE
B. I.  LIMITS  P. D.
SPECIAL CONDITIONS
STATE  N.Y.
OTHER
INSURED IS
IND.
PART.
CORP. X
OTHER
AUDIT
MONTHLY
QUARTERLY 
SEMI. ANNUAL

[[7 column table]]
| CLASSIFICATION | CODE | ESTIMATED EXPOSURE PER $100 PAYROLL | RATE PER $100 PAYROLL | ADVANCE PREMIUM PER $100 PAYROLL | AUDITED EXPOSURE PAYROLL | AUDITED PREMIUM |
|---|---|---|---|---|---|---|
| ART GALLERY RATED: | 8017 |   | .81 |   | 30425 | 246.00 |
| CLERICAL | 8810 |   | .16 |   | 28137 | 45.00 |
| EXECUTIVE OFFICERS NOC NOT FOREMEN WORKMEN OR SALESMEN | 8809 |   | .12 |   | 100 |   |
| L.C. 4.00 |   |   |   |   |   | 4.00 |
| E.C. 10.00 |   |   |   |   |   | 10.00 |
| U.S. LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT END. N.Y TRANSITION CREDIT CR. LONGSHOREMEN AND HARBOR WORKERS INCR. RATE END NEW YORK 7.0% | 0076 |   |   |   |   | 49.00CR. |
[[/table]]

MINIMUM PREMIUM  27.00
INFORMATION FROM OR REPORT SIGNED BY-
AUDITOR  WHALEN BOT 2/8/68  DATE OF AUDUT

REN U 293036 1

AS  3/8

TOTAL AUDITED PREMIUM 256.00
TOTAL ADVANCE PREMIUM 291.00
RETURN  PREMIUM 35.00

FORM G-3436D REV. 1-65

EXPLANATION OF ABBREVIATIONS
L.C. -LOSS CONSTANT
E.C. -EXPENSE CONSTANT
L.&E.C. - LOSS AND EXPENSE CONSTANT
S/R -SHORT RATE
P/R -PRO-RATA
M.P -MINIMUM PREMIUM

Transcription Notes:
---------- Reopened for Editing 2024-03-06 20:40:08 ---------- Reopened for Editing 2024-03-09 08:49:36