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PI-CXL-002 (05/19) <br />Ilil1111 [ova RRu�1 f <br />PREMIUM <br />PREMIUM SUBTOTAL $ 2,195.00 <br />STATE TAXES, FEES, SURCHARGES (if applicable) Not Applicable <br />PREMIUM TOTAL(including Taxes, Fees, Surcharges) $ 2,195.00 <br />AUDIT PERIOD: I ® NOTAPPLICABLE 10 ANNUALLY ❑ SEMI-ANNUALLY 10 QUARTERLY1 ❑ MONTHLY <br />SINESS <br />FORM OF BUSINESS: NON PROFIT ORGANIZATION <br />BUSINESS DESCRIPTION: Non -Profit Umbrella <br />PI-CXL-002 (05/19) <br />Ikntwm6rmRwmBr: <br />Reh M1Lmage,rmeUmulMtle <br />Page 2 of 5 <br />Includes copyrighted material of Insurance Services Office, Inc., with permission. <br />