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<br />-. <br /> <br />Policy Nu mber <br />92-GA-8133-8 <br /> <br />DECLARATIONS PAGE <br /> <br />AMENDED JUN 23 2007 <br /> <br /> <br />STATE FARM GENERAL INSURANCE COMPANY <br />900 OLD RIVER RD, BAKERSFIELD CA 93311-6000 <br />A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS <br /> <br />j\l- 200& - o&D- D/ <br /> <br />23-8821-F790 S <br /> <br />Named Insured and Mailing Address <br /> <br />GEORGE, MARIE <br />DBA ACT ONE ACADEMY OF DANCE <br />1186 N TUSTIN AVE <br />ORANGE CA 92867-6006 <br /> <br />Cov A -Inflation Coverage Index: N/A <br />BUSINESS POLICY - SPECIAL FORM 3 Cov B - Consumer Pricelndex: 203.9 <br />AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this pOlicy will be renewed automatically <br />subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we win <br />give you and the MortgageelLienholder written notice in compliance W11H the policy provisions or as required by law. <br />Policy Period: 12 Months The policy peri?d begins and ends at 12:01 am standard time at the <br />Effective Date: JUN 23 2007 premises location. <br />Expiration Date: JUN 23 2008 <br />Named Insured: Individual <br /> <br />Location of Covered Premises: <br />1186 N TUSTIN AVE <br />ORANGE CA 92867-6006 <br /> <br />Your policy is amended JUN 23 2007 <br />ADDL INSURED NAME & ADDRESS ADDED <br />ENDORSEMENT FE-6609 ADDED <br /> <br />Coverages & Property <br /> <br />Section I <br />A Buildings <br />B Business Personal Property <br />C Loss of Income - 12 Months <br /> <br />Limits of Insurance <br /> <br />Excluded <br />$ 5 800 <br />$ Actual loss <br /> <br />Section II <br />L Business Liability <br />M Medical Payments <br />Products-Completed Operations <br />(PCO) Aggregate <br />General Aggregate (Other <br />Than PCO) <br /> <br />I <br /> <br />1,000,000 <br />5,000 <br />2,000,000 <br />2,000,000 <br /> <br />Deductibles - Section I <br />$ 500 Basic <br /> <br />$ <br /> <br />Forms, Options, and Endorsements <br />Special Form 3 <br />*Section II Additional Insured <br />Amendatory Endorsement <br />Debris Removal Endorsement <br />Policy Endorsement <br />Business POlicy Endorsement <br />Glass Deductible - Section I <br />* New Form Attached <br /> <br />FP-6143 <br />FE -6609 <br />FE-6205 <br />FE -6451 <br />FE-6506.2 <br />FE-6464 <br />FE-6538.1 <br /> <br />In case of loss under this policy, the deductible will be <br />applied to each occurrence and will be deducted from the <br />amount of the loss. Other deductibJes may apply - refer to <br />policy. <br /> <br />Endorsement Premium <br />Increase $ 120.00 <br /> <br />Discounts Applied:APDD r",;, <br />Renewal Year . >.. 1. hV, AS <br />Ye~rs in Business .,...//J...J. .' .' <br />Claim Record ---~~i.r ,~::/L2/'. ..' j I J.. <br />, ':;1,--'-'~ <br />t. ~j;'::':'l . "A"..;..-.---- <br /> <br /> <br />Prepared <br />JUL 06 2007 <br />FP-8030.2C A3TN <br />06/1993 <br />Your policy consists of this page, any endorsements <br />and the policy form. PLEASE KEEP THESE TOGETHER. <br /> <br /> <br />avo 1 <br /> <br />Age nt <br /> <br />(o1f2172b) <br /> <br />