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'OkMutualLiberty <br />. <br />INSURANCE <br />Coverage Is Provided In: <br />West American Insurance Company - a stock company <br />Policy Change Endorsement <br />Named Insured Agent <br />GERALDINE VALENCIA <br />DBA: G STARS DANCE AND GYMNASTICS <br />SUMMARY OF LOCATIONS <br />0001 940 W Chapman Ave Ste 103C, Orange, CA 92868-2892 <br />POLICY FORMS AND ENDORSEMENTS <br />Policy Number: <br />BKW (21) 60 62 24 86 <br />Policy Period: <br />From 01/01/2020 To 01/01/2021 <br />Endorsement Period: <br />From 01/01/2020 to 01/01/2021 <br />12:01 am Standard Time <br />at Insured Mailing Location <br />(714)288-8000 <br />AA LAKES INSURANCE SERVICES INC <br />This section lists the Fors and Endorsements for your policy. Refer to these documents as needed for detailed <br />information concerning your coverage. <br />FORM NUMBER TITLE <br />CG 00 01 04 13 <br />Commercial General Liability Coverage Form - Occurrence <br />CG Ol 67 06 10 <br />California Changes - Public Schools <br />*CG 20 01 04 13 <br />Primary And Noncontributory - Other Insurance Condition <br />*CG 20 1004 13 <br />Additional Insured - Owners, Lessees or Contractors - Scheduled Person or <br />Organization <br />CG 21 0605 14 <br />Exclusion - Access Or Disclosure Of Confidential Or Personal Information And <br />Data -Related Liability - With Limited Bodily Injury Exception <br />CG 21 47 1207 <br />Employment -Related Practices Exclusion <br />CG 21 67 1204 <br />Fungi or Bacteria Exclusion <br />CG 21 7001 15 <br />Cap on Losses from Certified Acts of Terrorism <br />CG 21 7601 15 <br />Exclusion of Punitive Damages Related to a Certified Act of Terrorism <br />CG 21 8801 15 <br />Conditional Exclusion of Terrorism Involving Nuclear, Biological or Chemical <br />Terrorism (Relating to Disposition of Federal Terrorism Risk Insurance Act) <br />CG 22 30 07 98 <br />Exclusion - Corporal Punishment <br />BE VIEWiskED & APPROVED <br />A 11t <br />Issue Date 01/23/20 Authodzed Representative <br />To report a claim, call your Agent or 1-844-325.2467 <br />DS 70 27 01 08 <br />mmon SM794AR NaMI RR San NrAFPPNn INAIIRFn ropy mm7?c PAU 2 nF 17 <br />