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DocuSign Envelope ID: 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 <br />Insured Contact: Vince Tien <br />Work Phone: (323) 443-8888 <br />Email: vince.tien@360clinic.md <br />Producer Contact: Cynthia Wang <br />Work Phone: (626) 810-5556 <br />Email: info@wawainsurance.com <br />Effective: 01/18/2021 to 01/18/2022 <br />Loss History <br />Has the applicant had any losses associated with the lines quoted in the past three years? ............................ ❑ Yes ® No <br />1100 Locust St., Dept. 1100 Page 4 Des Moines,1A 50391-I100 <br />