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DocuSign Envelope ID: 2FEC7950-846A-4427-8D35-5C288A6B81A1 <br />0 Nationwide <br />Number: ACP 3009934033 <br />Schedule <br />Vehicle 1 <br />VIN <br />Garaging <br />Premises ID <br />Territory <br />Vehicle Type <br />Body Style <br />Valuation (Stated Amount) <br />Use <br />Class Code <br />WAWA CYNTHIA INSURANCE AGENCY <br />(626)810-5556 <br />360 Clinic <br />Commercial Insurance Application <br />Effective: 01/18/2021 to 01/18/2022 <br />Business Auto <br />2014 MERCEDES 3500 1 4X2 SPRINTER CARGO VAN, W/ABS HYD BRAKES, TRACTION <br />CONTROL, POWER STEERING <br />WD3PE8DC2E5834651 <br />1850 S West St Anaheim, CA 92802 - 3407 <br />186 <br />Private Passenger <br />Van <br />$ 15,000 <br />Driven to work or school <br />7382400 <br />Coverage <br />Limit <br />Deductible <br />Premium <br />Liability <br />$ 1,000,000 <br />$ 2,533.00 <br />Medical Payments <br />See State Schedule <br />$ 78.00 <br />Comprehensive <br />$ 500 <br />$ 64.00 <br />Specified Cause of Loss <br />No Coverage <br />Collision <br />$ 500 <br />$ 783.00 <br />Vehicle I Premium <br />$ 3,458.00 <br />State Schedule - CA <br />Limit <br />Deductible <br />Premium <br />Medical Payments <br />$ 5,000 <br />Uninsured Motorists Bodily Injury <br />$ 300,000 <br />$ 141.00 <br />1100 Locust St., Dept. 1100 Page 7 Des Moines, IA 50391-1100 <br />