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Philadelphia Indemnity Insurance Company <br />One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />COMMON POLICY DECLARATIONS <br />Policy Number: PHPK430634 <br />Named Insured and Mailing Address: Producer: <br />Raymundo Suarez Unassigned (SB), 6039 <br />610 S Townsend Street 26300 LA LALMEDA <br />Santa Ana, CA, 92703 MISSION VIEJO CA 92691 US <br />Policy Period From: To: <br />06/15/2009 06/15/2010 <br />at 12:01 A.M. Standard Time at your mailing address <br />shown above. <br />Business Description: Individual <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, <br />WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. <br />THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />Commercial Property Coverage Part <br />Commercial General Liability Coverage Part $122.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Businessowners <br />Workers Compensation <br />Taxes /Fees /Surcharges $50.00 <br />Total $172.00 <br />FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE <br />Refer To Forms Schedule <br />Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />CPD- PIIC (01/07) <br />&q- <br />Countersignature Date Authorized Representative <br />