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Philadelphia Indemnity Insurance Company <br />One Bale Plaza, Gubo10O.BalaCvnwy .Pemnuylvania1S00W <br />COMMON POLICY DECLARATIONS <br />Policy Number: PHPK503568^003 <br />Named Insured and Mailing Address; <br />Chih|mSano <br />106 Yorktown Ln <br />Costa Mesa, CA 92626- <br />NkaguireInsurance Agency, Inc, <br />271O1Puerta Real Suite 2OO <br />Mission Viejo, CA92O91^ <br />CPD-PUC(0107) <br />Policy Period From: 12/08/2014 To: 12/08/2015 ati2:oiAM. Standard Time atyour mailing <br />address shown above <br />Business Description: Fitness Trainer <br />IN RETURN FOR THE PAYMENT OF THE PREM|UK4, AND SUBJECT TOALL THE TERMS OF THIS POLICY, WE <br />AGREE WITH YOU TOPROVIDE THE INSURANCE 88STATED |NTHIS POLICY. <br />TH|SPDLICYCDNG|GT8VFTMEFOLLOVV|NGC0VERA8EPARTSF0RVVH|CHAPREMIU7N|G|ND|OATED,TH|G <br />PREMIUM MAY DESUBJECT TOADJUSTMENT. <br />PREMIUM <br />Commercial Property Coverage Part <br />Commercial General Liability Coverage Part $182.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Commercial Stop Gap Part <br />Bus|neaaownors <br />Workers Compensation <br />Taxes/Fees/Surcharges $50.00 <br />Total <br />--F-0—RM (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 />Countersignature Date <br />Authorized Representative <br />