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Report Claims to: LIA Administrators & Insurance Services, 800-334-0652, P.O. Box 1319, 1600 Anacapa St, <br />Santa Barbara, California 93101 <br />9.Annual Premium: <br />10.Forms attached at issue:LIA002 (04/19) LIA NC (05/19) LIA NC NOT (05/19) LIA012 (05/19) LIA020NC (05/19) <br />LIA112 (05/19) LIA164 (05/19) LIA165 (05/19) <br />$4,838.00 <br />8. <br />This Declarations Page, together with the completed and signed Policy Application including all attachments and exhibits thereto, and <br />the Policy shall constitute the contract between the Named Insured and the Company. <br />____________________________________ <br />Date <br />07/19/2023 By ______________________________________________________________ <br />Authorized Representative <br />Cust ID:113569 <br />LIA001 (04/19) <br />Aspen American Insurance Company Page 2 of 2 <br />DocuSign Envelope ID: 3D1A0201-2C5A-43CF-BDC1-C7B9405D331D