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Philadelphia Indemnity Insurance Company <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />Policy Number:PHPK670403-002 <br />I✓ See Supplemental Schedule <br />Agent #:6039 <br />LIMITS OF INSURANCE G <br />$3,000,000 General Aggregate Limit (Other Than Products — Completed Operation) <br />$3,000,000 Products/Completed Operations Aggregate Limit (Any One Person Or Organization) <br />$1,000,000 Personal and Advertising Injury Limit <br />$1,000,000 Each Occurrence Limit <br />$100,000 Rented To You Limit <br />$2,500 Medical Expense Limit (Any One Person) <br />FORM OF BUSINESS: Individual <br />Business Description: Fitness Trainer <br />Location of All Premises You Own, Rent or Occupy: SEE SCHEDULE ATTACHED <br />AUDIT PERIOD, ANNUAL, UNLESS <br />OTHERWISE STATED: <br />Rates <br />Advance Premiums <br />Premium <br />Prod./ <br />Prod./ <br />Classifications <br />Basis <br />Prem./Ops. Comp. Ops. <br />Prem./Ops. Comp. Ops. <br />SEE SCHEDULE ATTACHED <br />TOTAL PREMIUM FOR THIS COVERAGE PART: $122.00 Included <br />Retroactive Date(CG 00 02 Only) <br />This insurance does not apply to "Bodily Injury", "Property Damage", or "Personal and Advertising Injury" which occurs before the <br />retroactive date, if any, shown below. <br />Retroactive Date: <br />FORM(S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule <br />Countersignature Date Authorized Representative <br />AS T� FARM <br />APYR�v£� <br />�ORcK <br />�\S E_ S At�orrey <br />PSS`Staot City <br />Page 1 of 1 �/ P <br />