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Fitness and Wellness Insurance <br />A Member of Philadelphia Insurance Companies <br />Tel:877-438-7459 - Fax:866-847-4046 • CA License #0377645 <br />Name: Santiago Bautista Account #: 81676411 <br />Address: 1523 W 6th St Expiring Policy #: PHPK1086454-000 <br />Santa Ana, CA 92703- Renewal Date: 10/11/2014 <br />Policy Type: General and Professional Liability <br />Policy Limits: $1,000,000 l$3,000,000 <br />Total Balance Due`: $172.00 <br />Total charge Includes Insurance premium, applicable taxes, and a $50 Risk Purchasing Group administration fee that is fully earned and non- <br />refundable. if you have made changes to your operations, such as producing videos, leasing or purchasing a facility, or hiring employees, <br />please call customer service for a revised premium. <br />This payment notice is being sent thirty (30) days prior to the expiration of your current policy. Your policy has been automatically renewed and <br />issued and is enclosed. If payment is not received by your policy expiration date, your renewal will be automatically canceled. Available <br />payment options are below. <br />Questions? Please call customer service 877-438-7459 <br />If payment has already been made, please disregard this notice. If you do not wish to renew your current coverage, <br />please send an email to custsery nhlyins.com specifying the insured name and address, policy number, policy term, <br />effective date of cancellation and reason for cancellation. If this is brokered business please contact your agent to <br />cancel. <br />Please note the following payment options for renewal of your insurance coverage: <br />1. You can renew via Visa or MasterCard on-line at www.fitnessandwellness.com or by contacting our <br />customer service department at 877-438-7459. <br />2. You can renew via check made payable to Fitness and Wellness Insurance by mailing your <br />payment notice and check to: <br />Fitness and Wellness Insurance <br />P.0, Box 70251 <br />Philadelphia, PA 19176-0251 <br />Note: If you have a landlord, facility owner, or other party to be listed as an additional insured, <br />please attach a list including name and mailing address. <br />All correspondence should be sent to: <br />Philadelphia Insurance Companies <br />Attention: Customer Service <br />One Bala Plaza, Suite 100 <br />Bala Cynwyd, PA 19004 <br />Please detach here <br />® Fitness and Wellness Insurance <br />If you are an IDEA member and your membership has lapsed, please go to www.ideafit.com to activate <br />your membership prior to making payment. <br />Membership #: <br />Phone: <br />Membership Expiration Date: <br />Email: <br />Reviewed by <br />Ovia Cuevas <br />PRCSAIAdmir, <br />Name: Santiago Bautista <br />Account#:81676411 <br />Expiring Policy #: PHPK1086454.000 <br />,.xpiration Date: 10/11/2014 <br />Total Balance Due: $172.00 <br />