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• <br /> PS/ American Safety Indemnity Company <br /> 100 Galleria Parkway SE, Atlanta GA 30339 <br /> 800 -388 -3647 FAX 770955 -8339 <br /> E&S Fax Number (770) 955 -6163 <br /> AmERtairtSvErrhisurma <br /> THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE <br /> FORM(S) AND ANY ENDORSEMENT(S). COMPLETE THE ABOVE NUMBERED POLICY. <br /> Endorsement Effective: 12/21/2010 Countersigned By: <br /> Named Insured: <br /> GTB BUILDERS LLC <br /> (Authorized Representative) <br /> IN CONSIDERATION OF THE PAYMENT OF THE PREMIUMS, AND SUBJECT TO ALL THE TERMS, CONDITIONS AND <br /> EXCLUSIONS OF THIS POLICY, WE AGREE TO PROVIDE THE INSURED WITH THE INSURANCE AS STATED IN THIS POLICY. <br /> THESE DECLARATIONS TOGETHOR WITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S) AND ENDORSEMENTS <br /> ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE REFERENCED POLICY. <br /> Page3of3 <br /> L d6Z :Z0LlLZue <br />