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DocuSign Envelope ID: 2FEC7950-846A-4427-8D35-5C288A6B81A1 WAWA CYNPIIIA INSURANCE AGENCY <br />(626)810-5556 <br />Nationwide <br />360 Clinic <br />Commercial Insurance Application <br />Quote Number: ACP 3009934033 Effective: <br />01/18/2021 to 01/18/2022 <br />Business Auto <br />General <br />With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant? ............. <br />❑ Yes ld No <br />Is there a vehicle maintenance program in operation?........................................................ <br />ID Yes ❑ No <br />Are any vehicles leased to others?....................................................................... <br />❑ Yes ® No <br />Are any vehicles customized, altered or specially equipped? .................................................. <br />❑ Yes ® No <br />Does the applicant own or operate any vehicles that are not scheduled on this application? .......................... <br />❑ Yes FI No <br />Are there any scheduled vehicles that are not titled to the applicant? ............................................ <br />❑ Yes ® No <br />1100 Locust St., Dept. 1100 Page 5 Des Moines, IA 50391-1100 <br />