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DocuSign Envelope IDS 2FEC7950-846A-4427-8D35-5C288A6B81A1 WAWA CYNTMA INSURANCE AGENCY <br />(626)810-5556 <br />Nationwide' <br />360 Clinic <br />Commercial Insurance Application <br />Quote Number: ACP 3009934033 Effective: 01/18/2021 to 01/18/2022 <br />Binding Information <br />Agent 32075 - WAWA CYNTHIA INSURANCE AGENCY <br />Producer 002 - SHEN-BOB WANG <br />State Producer License Number 0796168 <br />Is Coverage Bound? Yes Date/Time Bound 01/22/2021 11:40 AM CST <br />Account Summary <br />Coverage Type Policy Prefix Company Premium <br />Business Auto BA Nationwide Mutual Insurance Company $ 3,750.76 <br />Total Premium: $ 3,750.76 <br />quote is based on information provided and rates in force at the time of quotation and is subject to underwriting. Any <br />ges to the information submitted, made for any reason, including but not limited to underwriting actions, loss control, <br />ication and validation of information or changes initiated at the time of submission, may result in a change in the final <br />.ium offered. <br />:rage is not bound and no coverage will be afforded by this quotation. This insurance quote is not a part of the insurance <br />y. If there is any discrepancy in the coverages shown in this quote and that of the actual policy issued, the policy <br />Baling Summary <br />Billing Method : Direct Bill <br />Down Payment Amount: $3,750.76 <br />Billing Frequency: Annual (In Full Per Policy Term) <br />Down Payment Method: Credit Card <br />Suspense Number: 9147791 <br />Flex Chek : No <br />The applicant has read, understands, and agrees to abide by the terms and conditions outlined in this application ......... X) Yes ❑ No <br />By checking this box, I am providing my electronic signature to this document. Agent Signature: ..................... ® Yes ❑ No <br />The ande¢sstlpR?3't�gli5dQM onzed representative of the applicant and certifies that reasonable inquiry has been made to obtain the answers to <br />question t is p ' t t on. He/She certifies that the answers are true, correct and complete to the best of his/her knoft2021 <br />0068CCC69769741B... <br />Applicant's Signature Date <br />1100 Locust St., Dept. 1100 Page 1 Des Moines, IA 50391-I100 <br />