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* 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO <br />*D/B* 072977484 262428 <br />GAI 6001 (Ed. 06 97) <br />Policy No. UMB 3-96-14-61 - 00 <br />Renewal Of - <br />THE PROTECTOR COMMERCIAL UMBRELLA DECLARATIONS PAGE <br />1 NAMED INSURED AND ADDRESS: 2. POLICY PERIOD: <br />BACKHAUS DANCE 12:01 A.M. Standard Time at the <br />address of the Named Insured <br />P.O. BOX 5890 shown at left. <br />ORANGE, CA 92863 From 06/03/2021 To 06/03/2022 <br />IN RETURN FOR PAYMENT OF THE PREMIUM, PRODUCER'S NAME AND ADDRESS: <br />AND SUBJECT TO ALL TERMS OF THIS MAURY DONNELLY & PARR INC <br />POLICY, WE AGREE WITH YOU TO PROVIDE <br />THE INSURANCE AS STATED IN THIS 24 COMMERCE ST <br />POLICY. BALTIMORE, MD 21202 3208 <br />Insurance is afforded by: GREAT AMERICAN <br />ALLIANCE INSURANCE COMPANY <br />3. PREMIUM: Commercial Umbrella Premium $ 3,250.00 <br />Total Advance Premium $ 3,250.00 <br />Total $ 3,250.00 <br />In the event of cancellation by the Named Insured, the company will receive <br />and retain no less than $ 650.00 as a policy minimum premium. <br />BASIS OF PREMIUM: Non - Auditable ( X) Auditable ( ) <br />4. LIMITS OF INSURANCE: $ 4,000,000 Each Occurrence <br />$ 4,000,000 General Aggregate (Where Applicable) <br />$ 4,000,000 Products -Completed Operations Aggregate <br />5. SELF -INSURED RETENTION: $ 10 , 000 <br />6. FORMS AND ENDORSEMENTS applicable to all Coverage Forms and made part of <br />this Policy at time of issue are listed on the attached Forms and <br />Endorsements Schedule, GAI 6013 (Ed. 06/97). <br />GAI 6001 (Ed. 06/97) PRO (Page 1 of 1 ) <br />HORaN <br />} z <br />RiskMwag medDMsian <br />REVIEWED & APPROVED BY.- <br />f R. V;d <br />Risk Management Analyst <br />