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081 * 06/07/2021 * UMB 3952752 00 GREAT AMERICAN ALLIANCE INS CO <br />*D/B* 121126296 255044 <br />GAI 6001 (Ed. 06 97) <br />Policy No. UMB 3-95-27-52 - 00 <br />Renewal Of <br />THE PROTECTOR COMMERCIAL UMBRELLA DECLARATIONS PAGE <br />1. NAMED INSURED AND ADDRESS: <br />2. POLICY PERIOD: <br />BENEVOLENT & PROTECTIVE ORDER <br />12:01 A.M. Standard Time at the <br />OF ELKS #794; SANTA ANA ELKS <br />address of the Named Insured <br />1751 S LYON ST <br />shown at left. <br />SANTA ANA, CA 92705 5009 <br />From 05/29/2021 To 05/29/2022 <br />IN RETURN FOR PAYMENT OF THE PREMIUM, <br />PRODUCER'S NAME AND ADDRESS: <br />AND SUBJECT TO ALL TERMS OF THIS <br />ARMSTRONG/ROBITAILLE/RIEGLE <br />POLICY, WE AGREE WITH YOU TO PROVIDE <br />THE INSURANCE AS STATED IN THIS <br />830 ROOSEVELT STE 200 <br />POLICY. <br />IRVINE, CA 92620 3663 <br />Insurance is afforded by: GREAT AMERICAN <br />ALLIANCE INSURANCE <br />COMPANY <br />3. PREMIUM: Commercial Umbrella Premium $ 2,149.00 <br />Total Advance Premium <br />$ 2,149.00 <br />Total $ 2,149.00 <br />In the event of cancellation by the Named Insured, the company will receive <br />and <br />retain no less than $ <br />430.00 as a policy minimum <br />premium. <br />BASIS <br />OF PREMIUM: Non-Auditable ( X) Auditable ( ) <br />4. <br />LIMITS OF INSURANCE: $ <br />1,000,000 Each Occurrence <br />$ <br />1,000,000 General Aggregate <br />(Where Applicable) <br />$ <br />1,000,000 Products -Completed <br />Operations Aggregate <br />5. <br />SELF -INSURED RETENTION: <br />$ 10,000 <br />6. <br />FORMS AND ENDORSEMENTS <br />applicable to all Coverage Forms <br />and made part of <br />this Policy at time of <br />issue are listed on the attached <br />Forms and <br />Endorsements Schedule, <br />GAI 6013 (Ed. 06/97). <br />GAI 6001 (Ed. 06197) PRO (Page 1 of 1) <br />