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DocuSign Envelope ID:87BF107D-405E-4C76-B5D4-6AE86312F5CC <br /> • <br /> OW/11112 Fitness and Wellness Insurance <br /> owl* <br /> A Member of Philadelphia Insurance Companies z <br /> ;J <br /> Tel: 877-438-7459 • Fax: 866-847-4046 • CA License#0377645 <br /> Name: Barbara Jan Lang Account#: 78975689 <br /> Address: 905 Cedar Fork Trail Expiring Policy#: PHPK596174-006 <br /> Chapel Hill, NC 27514- Renewal Date: 07/10/2017 <br /> Policy Type: General and Professional Liability <br /> Policy Limits: $2,000,000/$4,000,000 <br /> Total Balance Due*: $125.00 <br /> Total charge includes insurance premium, applicable taxes, and a $50 Risk Purchasing Group administration fee <br /> that is fully earned and non-refundable. If you have made changes to your operations, such as producing videos, <br /> leasing or purchasing a facility, or hiring employees, please call customer service for a revised premium. <br /> This payment notice is being sent thirty (30) days prior to the expiration of your current policy. Your policy has <br /> been automatically renewed and issued and is enclosed. If payment is not received by your policy expiration date, <br /> your renewal will be automatically canceled. Available payment options are below. <br /> Questions? Please call customer service 877-438-7459 <br /> If payment has already been made, please disregard this notice. If you do not wish to renew your current coverage, <br /> please send an email to service(a�phlv.com specifying the insured name and address, policy number, policy term, <br /> effective date of cancellation and reason for cancellation. If this is brokered business please contact your agent to <br /> cancel. <br /> I� II <br /> Please note the following payment options for renewal of your insurance coverage: <br /> 1. You can renew via Visa or MasterCard on-line at www.fitnessandwellness.com or by contacting our <br /> customer service department at 877-438-7459. <br /> 2. You can renew via check made payable to Fitness and Wellness Insurance by mailing your <br /> payment notice and check to: <br /> Fitness and Wellness Insurance <br /> P.O. Box 70251 <br /> Philadelphia, PA 19176-0251 <br /> Note: If you have a landlord, facility owner, or other party to be listed as an additional insured, <br /> please attach a list including name and mailing address. <br /> All correspondence should be sent to: <br /> Philadelphia Insurance Companies <br /> Attention: Customer Service <br /> One Bala Plaza, Suite 100 <br /> Bala Cynwyd, PA 19004 <br /> Please detach here <br /> I\Ii%, <br /> Fitness and Wellness Insurance <br /> If you are an IDEA member and your membership has lapsed, please go to www.ideafit.com to activate <br /> your membership prior to making payment. <br /> Membership#: Membership Expiration Date: <br /> Phone: Email: <br /> Name: Barbara Jan Lang <br /> Account#: 78975689 <br /> Expiring Policy#: PHPK596174-006 <br /> Expiration Date: 07/10/2017 <br /> Total Balance Due: $125.00 <br />