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DocuSign Envelope ID: 2FEC7950-846A-4427-BD35-5C288A6B81A1 WAWA CYNTRIA INSURANCE AGENCY <br />(626)810-5556 <br />Nationwide <br />360 Clinic <br />Commercial Insurance Application <br />Quote Number: ACP 3009934033 <br />Effective: 01/18/2021 to 01/18/2022 <br />Notice of Insurance Information Practices <br />Personal information about you, including information from a creditor other investigative report, may be collected from persons other than <br />you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal <br />and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your <br />authorization. Credit scoring information may be used to help determine either your eligibility for insurance or the premium you will be <br />charged. We may use a third party in connection with the development of your score. You may have the right to review your personal <br />information in our files and request correction of any inaccuracies. You may also have the right to request in writing that we consider <br />extraordinary life circumstances in connection with the development of your credit score. These rights may be limited in some states. Please <br />contact your agent or broker to learn how these rights may apply in your state or for instructions on how to submit a request to us for a more <br />detailed description of your rights and our practices regarding personal information. <br />(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or W V.) <br />The applicant has read, understands, and agrees to abide by the terms and conditions outlined in this application ......... 13 Yes ❑ No <br />By checking this box, I am providing my electronic signature to this document. Agent Signature: ..................... in Yes ❑ No <br />The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the answers to <br />questionyMFI 1S"Ep RlAtion. He/She certifies that the answers are true, correct and complete to the best of his/her knowledge. <br />1/22/2021 <br />Applicant's <br />Date <br />1100 Locust St., Dept. 1100 Page 2 Des Moines, IA 50391-1100 <br />