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DocuSign Envelope ID:8C7A270E-432E-42E0-A5B7-5136E53010EC <br /> CPD-PIIC (01/07) <br /> Philadelphia Indemnity Insurance Company <br /> One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br /> COMMON POLICY DECLARATIONS <br /> Policy Number: PHPK1542474-000 <br /> Named Insured and Mailing Address: Producer: 6039 <br /> Rena Springer Maguire Insurance Agency, Inc. <br /> 1101 Exchange Place Apt 838 27101 Puerta Real Suite 200 <br /> Durham, NC 27713- Mission Viejo, CA 92691- <br /> Policy Period From: 08/31/2016 To: 08/31/2017 at 12:01 AM.Standard Time at your mailing <br /> address shown above <br /> Business Description: Fitness Trainer <br /> Style/Art: Pilates <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 $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 /> Countersignature Date Authorized Representative <br />