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STILLWATER <br />INSURANCE COMPANY <br />AMENDED <br />Modified Additional Interest <br />Stillwater Insurance Group <br />PO BOX 45126 <br />JACKSONVILLE FL 32232-5126 <br />855-712-4114 <br />CHANGE EFFECTIVE 02/08/2023 <br />BUSINESS OWNER POLICY DECLARATIONS <br />Named Insured and Mailing Address Policy Number BP2002952 <br />VIETNAMESE LANGUAGE ACCESS/ASSISTANCE (VIETLA) Agency —and Service Contact <br />1056 CABRILLO PARK DR #B <br />SANTA ANA CA 92701-4439 ARC 23 INSURANCE SERVICES <br />(949)484-7500 <br />Policy Period 09/28/2022 to 09/28/202312:01AM Standard Time at the Premises location <br />** THIS POLICY DOES NOT COVER EARTHQUAKE OR FLOOD DAMAGE ** <br />In return for timely payment and subject to all policy terms and conditions, we agree with you to provide insurance as <br />stated in this policy, declarations, and every applicable form and endorsement. Also: <br />- Amount of insurance limits shown are not stackable across locations or buildings; <br />- With respect to Business Liability and Medical Expenses - each claim paid reduces the amount of insurance <br />provided during the applicable annual period; and, <br />- If coverage limits or deductibles are indicated "included" refer to policy provisions for coverage, <br />conditions, and amount of insurance details. <br />PREMIUM AND FEES <br />Annual Premium <br />$ <br />576.05 <br />Terrorism - Certified Acts <br />$ <br />3.80 <br />Policy Fee - New Business <br />$ <br />50.00 <br />Total Annual Premium & Charges <br />$ <br />629.85 <br />SB DS 01 11 17 <br />004100000000000295223041 0000C <br />Risk Mancgmtent DMitimt <br />REVIEiwE➢ 6 APPRQY® Sr: <br />A, fi Auv44 <br />112� <br />® <br />Risk Management Specialist <br />