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CPD-PIIC (01/071 <br />Philadelphia Indemnity Insurance Company <br />One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />COMMON POLICY DECLARATIONS <br />Policy Number: PHPK1086454-001 <br />Named Insured and Mailing Address: Producer: 6039 <br />Santiago Bautista Maguire Insurance Agency, Inc. <br />1523 W 6th St 27101 Puerto Real Suite 200 <br />Santa Ana, CA 92703- Mission Viejo, CA 92691- <br />Policy Period From: 10/11/2014 To: 10/11/2015 at 12:01 AM. standard Time at your mailing <br />address shown above <br />Business Description: Fitness Trainer <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE <br />AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED, THIS <br />PREMIUM MAYBE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />Commercial Property Coverage Part <br />Commercial General Liability Coverage Part $122.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Commercial Stop Gap Part <br />Businessowners <br />Workers Compensation <br />Taxes/Fees/Surcharges $50.00 <br />_ Total $172.00 <br />FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE <br />*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />Countersignature Date <br />Authorized Representative <br />Reviewed by: <br />Silvia Cuevas 7/ <br />