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Policy Number <br />92-GA-8133-8 <br />DECLARATIONS PAGE AMENDED JUN 23 2007 <br />-s <br />900 OLDERIVER RD, BAKERSFIE RD CA 939 ~1 6000 <br />A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS <br />h'- Z voles - coo- o~ <br />Named Insured antl Mailing Adtlress <br />23-8821-F790 S <br />GEORGE, MARIE <br />DBA ACT ONE ACADEMY OF DANCE <br />1186 N TUSTIN AVE <br />ORANGE CA 92867-6006 <br />BUSINESS POLICY -SPECIAL FORM 3 Cov A -Inflation Coveragge Index: NIA <br />Cov B -Consumer Pricelndex: 203.9 <br />AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policyy will be renewed automatically <br />subject to the premiums, rul¢¢s and forms in effect for each succeedingg policy period. if Phis icy Is terminated, we will <br />give you and the Mortgagee/Llenholder Written notice in compliance with the policy provisions or as required by law- <br />Policy Period: 12 Months The policy period 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 />Location of Covered Premises: <br />1186 N TUSTIN AVE <br />ORANGE CA 92867-6006 <br />Coverages & Property Limits of Insurance <br />Section I <br />A Buildings Exc 1 uded <br />B Business Personal Property $ 5 800 <br />C Loss of Income - 12 Months $ Actual doss <br />Section II <br />L Business Liability 1 000 000 <br />M Medical Payments 5'000 <br />Products-Completetl Operations 2,000;000 <br />(PCO) Aggregate <br />General Aggregate (Other $ 2,000,000 <br />Than PC ) <br />Forms, Options, and Endorsements <br />'Section II AddAional 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 />liontinUeO On R2VefSe Side Of Page <br />FP-6143 <br />FE-6609 <br />FE-6205 <br />FE-6451 <br />FE-6506.2 <br />FE-6464 <br />FE-6538.1 <br />Your policy is amentled JUN 23 2007 <br />ADDL INSURED NAME & ADDRESS ADDED <br />ENDORSEMENT FE-6609 ADDED <br />Deductibles -Section 1 <br />$ 500 Basic <br />In case of loss under this policy. the deductible will be <br />applied to each occurrence and well be deducted from the <br />amount of the loss. Other deductibles may apply -refer to <br />nnllnv <br />Endorsement Premium <br />Increase <br />120.00 <br />RlenewaSYea~ied:APE R~",%ir" ~,~; f't> <br />Years in Business ~ `~`l <br />Claim Record -~i~ ~~~ ~ <br />-- ~~~-;: 1 ~ -- <br />i ~~~ <br />.- ~s :_ ,. <br />Prepared OTHER LIMITS AND EXCLUSIONS MAY APPLY -REFER TO YOUR POLICY <br />lUL 06 2007 Counte signed <br />)6/ 993 .2C A3TN gy <br />lour policy consists of this page, any endorsements CHARLENE HATAKEYAMA <br />end the policy form. PLEASE KEEP THESE TOGETHER. (714) 527-see? <br />~O1 <br />(a1f2172b) <br />