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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number:PHPK1086454-001 <br />9— See Supplemental Schedule <br />LIMITS OF INSURANCE <br />$3,000,000 <br />$3,000,000 <br />$1,000,000 <br />$1,000,000 <br />$100,000 <br />$2,500 <br />Agent #:6039 <br />General Aggregate Limit (Other Than Products — Completed Operation) <br />Products/Completed Operations Aggregate Limit (Any One Person Or Organization) <br />Personal and Advertising Injury Limit <br />Each Occurrence Limit <br />Rented To You Limit <br />Medical Expense Limit (Any One Person) <br />FORM OF BUSINESS: Individual <br />Business Description: Fitness Trainer <br />Location of All Premises You Own, Rent or Occupy: SEE SCHEDULE ATTACHED <br />AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STATED: <br />Classifications <br />Premium <br />Basis <br />Rates <br />Prodd <br />Prom./Ops. Comp.Ops. <br />Advance Premiums <br />Prod./ <br />Prom./Ops. Comp.Ops. <br />SEE SCHEDULE ATTACHED <br />TOTAL PREMIUM FOR THIS COVERAGE PART: $122.00 Included <br />Retroactive Date(CG 00 02 Only) <br />This insurance does not apply to "Bodily Injury", 'Property Damage", or "Personal and Advertising Injury" which occurs before the <br />retroactive date, if any, shown below. <br />Retroactive Date: <br />FORM(S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br />Countersignature Date Authorized Representative <br />Reviewed by: <br />Silvia Cuevas <br />PRCSA/Admin. <br />Page 1 of 1 <br />