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<br />Sequoia Iusurance Company <br />P.O. Ro, 1510, Monterey, CA 93942 <br /> <br />. <br /> <br />Policy Number: SBP204616-1 <br />Luis E Rivera MD, Inc <br /> <br />BUSINESSOWNERS INSURANCE POLICY <br />Effecti\'c 07/19/2006 Declaration Number 001 <br />Policy Effective from 07/19/2006 tn 07/19/2007 at 12:0 1 AM Local Time <br /> <br />/ <br /> <br />Named Insured: <br />Luis E Rivera MD, Ine <br />2222 S Main Street <br />Santa Ana, CA 92707 <br /> <br />A~enq: 91390 <br />Networked Insurance Agents <br />988 MeCourtney Road <br />Grass Valley, CA 95949 <br />(530) 274-3102 <br /> <br />Form of Business: <br />Business Description: <br /> <br />Corporation <br />Medical office-urug pre screening <br /> <br />NEW Policy Declaration <br /> <br />These declarations together with the coverage forms, and endorscmenls added thereto, if any, issued to fann a part thereof, <br />complete the ahove numbered policy. <br /> <br />Your full term Premium Charge is $ ],171. An invoice with the payment plan will be mailed Lu you. <br /> <br />L <br /> <br />I In return for the payment of the premium, an~ suhjed to all the terms of this policy, we agree 10 provide the insurance <br />, stated in this policy. <br /> <br />COVERAGE <br /> <br />PREMIIJM <br /> <br />Busincssowncrs Policy Coyt~rage <br />Certified Terrorism Act Coverage <br /> <br />$1,Wi <br />$5 <br /> <br />"....,. <br /> <br /><;~.-r~1 <br /> <br />Sub-Total <br />CA Surcharge <br /> <br />$ 1,171 <br />$0 <br /> <br />TOTAL <br /> <br />$1,171 <br /> <br />Payment Plan: <br /> <br /> <br /> <br />r Countersigned: <br />I <br />I <br /> <br />2SC;1) Down & 8 Monlhly Pmts after 2 mos <br /> <br />(;ZQ// ill // ~d lk'ft€k <br /> <br />Date: July 25, 2006 <br /> <br />Authorized Representatives <br /> <br />Date Printed 07/25/2006 <br /> <br />INSURED <br /> <br />BOPC",'o,:-lRE-. <br />