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TRAVELERS!' <br />One Tower Square, Hartford, Connecticut 06183 <br />TRAVELERS CORP. TEL: 1-800-328-2189 <br />MM: INFO TECH <br />COMMON POLICY DECLARATIONS <br />ISSUE DATE: 10/21/21 <br />POLICY NUMBER: H-630-5A888588-TIA-21 <br />INSURING COMPANY: <br />THE TRAVELERS INDEMNITY COMPANY OF AMERICA <br />1. NAMED INSURED AND MAILING ADDRESS: <br />TOTAL ADMINISTRATIVE SERVICES <br />CORPORATION (AS PER IL T8 00) <br />2302 INTERNATIONAL IN <br />MADISON, WI 53704-3136 <br />2. POLICY PERIOD: From 10/01/21 to 10/01/22 12:01 A.M. Standard Time at <br />your mailing address. <br />3. LOCATIONS <br />Premises Bldg. <br />Loc. No. No. Occupancy <br />SEE IL TO 03 <br />Address <br />4. COVERAGE PARTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: <br />DELUXE PROPERTY COVERAGE PART DECLARATIONS DX TO 00 11 12 TIA <br />COMMERCIAL GENERAL LIABILITY COV PART DECLARATIONS CG TO 01 11 03 TIA <br />EMPLOYEE BENEFITS LIABILITY COV PART DECLARATIONS CG TO 09 09 93 TIA <br />5. NUMBERS OF FORMS AND ENDORSEMENTS <br />FORMING A PART OF THIS POLICY: SEE IL T8 01 10 93 <br />6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy <br />containing its complete provisions: <br />Policy Policy No. Insuring Company <br />NAME AND ADDRESS OF AGENT OR BROKER: <br />M3 INS SOLUTIONS INC (G7464) <br />828 JOHN NOLEN DR <br />MADISON, WI 53713 <br />IL TO 02 11 89(REV. 09-07) PAGE 1 OF 1 <br />OFFICE: CHICAGO <br />COUNTERSIGNED BY: <br />Authorized Representative <br />M __ <br />ew cF RAMwagmedDMsian <br />Jy/\'x REVIEWED & APPROVED BY: <br />V"° <br />--� Risk janagement Analyst <br />