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15.08.2019 15:24 17145444996 #0217 F 12/19 <br />FARMERS <br />INSURANCE <br />Named ERIC GRUVER <br />Insured <br />Truck Insurance Exchange (A Reciprocal Insurer) <br />Member Of The Farmers Insurance Group Of Companies'e <br />Home Office: 6301 Owensmouth Ave., Woodland Hills, GA 91367 <br />COMMON POLICY DECLARATIONS <br />Mailing 2021E FOURTH STE 116 <br />Address SANTA ANA, CA 92705 <br />Form of ©Individual ❑joint Venture <br />Business ❑Corporation ❑Partnership <br />F005238941.001.00001 <br />Account No. prod. Count <br />97-15-520 015041-40-07 <br />Agent No. Policy Number <br />❑ Limited Liability Co. Business Description: <br />❑ Other Organization Health Practitioners <br />Policy From 08.25.2019 (not priorto time applisd for) <br />Period To 08-25.2020 12:01A.M, Standard time atyour mallingaddress shown above. <br />If this policy replaces other coverage that ends at noon standard time of the same day this policy begins, this policy will not take effect <br />until the other coverage ends. This policy will continue for successive policy periods as follows: If we elect to continue this <br />Insurance, we will renew this policy if you pay the required renewal premium for each successive policy period subject to our <br />premiums, rules and forms then In effect. <br />The attorney -in -fact (AIF) or management fee foryour renewed policy will never exceed 20%of the policy's premiums and will be paid <br />out of the premiums. You may wish to consider this Information In deciding whether to accept or decline this offer to renew your policy. <br />This policy consists of the following coverage parts listed belowand for which a premium Is indicated. This premium may be subject to <br />change. <br />uoverage rarra Premium After Discount And Modification <br />Buslnessowners $702.00 <br />Employment Practices Liability $74,00 <br />Cyber LIabilityAnd Data Breach Expense Coverage $80,00 <br />Total (See Additional Fee l nformatlon Below) $856.00 <br />56-2406 1-17 �r C2406201 Page 1 0} 3 <br />55-240 iO3 `f�11 <br />