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Philadelphia Indemnity Insurance Company <br />One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />COMMON POLICY DECLARATIONS <br />Policy Number: PHPK2324258-000 <br />Named Insured and Mailing Address: <br />mtorres alvarez <br />2222 S Mohawk Ave <br />Santa Ana, CA 92704- <br />Producer: 125725 <br />Maguire Insurance Agency, Inc. FWI <br />1 Bala Piz Ste 100 <br />Bala Cynwyd, PA 19004-1401 <br />CPD-PIIC (01/07) <br />Policy Period From: 09/09/2021 To: 09/09/2022 at 12:01 AM, Standard Time at your mailing <br />address shown above <br />Business Description: Fitness Trainer <br />Style/Art: Martial Arts <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE <br />AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS <br />PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />Commercial Property Coverage Part <br />Commercial General Liability Coverage Part $122.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Commercial Stop Gap Part <br />Businessowners <br />Workers Compensation <br />Taxes/Fees/Surcharges $50.00 <br />Total $172.00 <br />FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE <br />Refer To Forms Schedule <br />`Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />Countersignature Date <br />9)4- <br />Authorized Representative <br />"Mall Wm�DFPIKIVe7 BY. ?J� <br />Risk Management Analyst <br />01 <br />