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FAPM RIA RI IIAI 1Al/ RL-A1 I1 TIARIC <br />Renewalof SCOTTSDALE INSURANCE COMPANY'' Policy Number <br />CPS2237135 CF'52561230 <br />Home Office: <br />One Nationwide Plaza R Columbus, Ohio 43215 <br />Administrative Office: <br />8877 North Gainey Center Drive e Scottsdale, Arizona 85258 <br />1-800-423-7675 <br />A STOCK COMPANY <br />ITEM 1. Named Insured and Mailing Address <br />HIBA SHUBLAK DBA: ACTIVE LEARNING <br />.t/ 14 SURFSIDE COURT <br />NEWPORT BEACH, CA 92663 <br />Agent Name and Address <br />✓COASTAL BROKERS INSURANCE SERVICES <br />6602 OWENS DRIVE SUITE 300 <br />PLEASANTON, CA 94588 Agent No.: 04068 Program No.: BM <br />ITEM 2. Policy Period From: 11/26/20IG TO: 11/26/2017 / Term: 365 DAYS <br />12:01 A.M., Standard Time at the mailing address shown in ITEM 1. <br />Business Description: DANCE INSTRUCTOR <br />In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the <br />insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. <br />Where no premium is shown, there is no coverage. This premium may be subject to adjustment. <br />Coverage Part(s) Premium Summary <br />Commercial General Liability Coverage Part <br />Commercial Property Coverage Part <br />Commercial Crime And Fidelity Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Professional Liability Coverage Part <br />Gov <br />�®\gib (NO <br />$ NOT COVERED <br />Total Policy Premium: $ 1. 920.00 <br />3W State Tax $ 57.60 <br />0.200% Stamp Fee $ 3.84 <br />Total: $ 1,981.44 <br />Form(s) and Endorsement(s) made a part of this policy at time of issue: <br />SEE SCHEDULE OF FORMS AND ENDORSEMENTS <br />B. HAUN/CY <br />Countersigned Date: <br />11/2/16 <br />THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH <br />THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, <br />COMPLETE THE ABOVE NUMBERED POLICY. <br />OPS-D-1 (8-10) INSURED opsdij . fap <br />