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DocuSign Envelope ID: 2FEC7950-846A-4427-8D35-5C288A6881A1 WAWA CYNTHIA INSURANCE AGENCY <br />(626)810-5556 <br />Nationwide <br />360 Clinic <br />Commercial Insurance Application <br />Quote Number: ACP 3009934033 Effective: O1/18/2021 to O1/18/2022 <br />Business Auto <br />Policy 1 : BA Total Policy Premium $ 3,750.76 <br />States of Operation: California <br />Primary Operations State: California <br />Premium for Certified Acts of Terrorism $ 0.00 <br />Policy Surcharges <br />CA- California Fraud Assessment <br />$ 1.76 <br />Policy Coverage <br />Coverage <br />Limit <br />Deductible Premium <br />Symbols <br />Liability <br />07,09 <br />$ 1,000,000 <br />$ 2,683.00 <br />Medical Payments <br />07 <br />See State Schedule <br />$ 78.00 <br />Uninsured Motorists <br />07 <br />See State Schedule <br />$ 141.00 <br />Comprehensive <br />07 <br />See Schedule $ 64.00 <br />Specified Cause of Loss <br />No Coverage <br />Collision <br />07 <br />See Schedule $ 783.00 <br />* Note: UM and UIM coverages are provided on a non -stacked basis unless indicated otherwise in the State Schedule <br />Covered Auto Symbols <br />(1) Any Auto Including Non -Owned and (4) Owned Autos other than Private Passenger (7) Autos Specified on Schedule <br />Hired <br />(2) All Owned Autos (5) All Owned Autos which require No -Fault Coverage (8) Hired Autos <br />(3) Owned Private Passenger Autos (6) Owned Autos Subject to Compulsory U.M. Law (9) Non -Owned Autos <br />(19) Mobile Equipment Subject to Auto <br />Laws <br />Policywide Options Limit Deductible Rating Basis Exposure Premium <br />Non -Owned Auto Coverage # of Employees 4 <br />CA, Territory 186 <br />Liability $ 1,000,000 $ 150.00 <br />Policywide Characteristics <br />Are all owned autos included in this quote?................................................................ ❑ Yes ® No <br />Are any federal or state motor carrier filings required?....................................................... ❑ Yes X No <br />Do operations involve transporting hazardous materials as defined by state or federal regulatory agencies? ............. ❑ Yes M No <br />1100 Locust St., Dept. 1100 Page 6 Des Moines, IA 50391-1100 <br />