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POLICY NUMBER: Pxos777844 <br />PREMIUM <br />PREMIUM SUBTOTAL <br />STATE TAXES, FEES, SURCHARGES (if applicable) <br />PI-CXL-002 (05/19) <br />Not <br />3,734.001 <br />PREMIUM TOTAL(including Taxes, Fees, Surcharges) $ 3,734.00 <br />AUDIT PERIOD: 112 NOTAPPLICABLE 10 ANNUALLY ❑ SEMI-ANNUALLY ❑ QUARTERLY1 ❑ MONTHLY <br />OF BUSINESS <br />FORM OF BUSINESS: NON PROFIT ORGANIZATION <br />BUSINESS DESCRIPTION: Non -Profit umbrella <br />PI-CXL-002 (05119) <br />Rid. M.vg.L Df <br />( �nesID6AreRavID Br. <br />'W� L /OSC )]iCLON <br />RukN „a9er,m� C1m W AiAe <br />Page 2 of 5 <br />Includes copyrighted material of Insurance Services Office, Inc., with permission. <br />