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Philadelphia Indemnity Insurance Company <br />iN One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />COMMON POLICY DECLARATIONS <br />Policy Number: PHPKI086454-002 <br />Named Insured and Mailing Address: <br />Santiago Bautista <br />1522 W 6th St <br />Santa Ana, CA 92703- <br />Producer: 6039 <br />Maguire Insurance Agency, Inc. <br />27101 Puerto Real Suita 200 <br />Mission Viejo, CA 92691- <br />CPDPIIC (01/07) <br />Policy Period From: 10/11/2015 To: 10/11/2016 at 12M AM, Standard Time at your maillog <br />address shown above <br />Business Description: Fitness Trainer <br />StylelArt: Martial Arts <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE <br />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. THIS <br />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 />Commercial Stop Gap Part <br />Businessowners <br />Workers Compensation <br />Taxes/Fees/Surcharges $50Ao <br />Total $172.00 <br />*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />Countersignature Date <br />Authorized Representative <br />Reviewed by <br />Carmen Acosta <br />PRCSA/Recreatior) <br />