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THIS PREMIUM MAY BE SUBJECT TO AUDIT TOTAL $1,151.00 <br />This premium does not include Taxes and Surcharges. <br />Taxes and Surcharges TOTAL $0.00 <br />The Forms) and Endorsement(s) made a part of this policy at the time of issue are listed on the SCHEDULE of FORMS and <br />ENDORSEMENTS. <br />Countersigned this 18 day of 06/2022 <br />Authorized Representative <br />THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART FORM(S), FORMS AND <br />ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. <br />FORM NO. -TERRITORY (EDITION) <br />Page 2 of 2 <br />Risk MamigmiadDhisian <br />E <br />REVIEWED & APPROVED BY. <br />e Aeevulo <br />'�--'Risk Management Specialist <br />