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Philadelphia Indemnity Insurance Company <br />One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />Policy Number: PHPK803569 -002 <br />Named Insured and Mailing Address: <br />Chihiro Sano <br />106 Yorktown Ln <br />Costa Mesa, CA 92626- <br />COMMON POLICY DECLARATIONS <br />Producer: 6039 <br />Maguire Insurance Agency, Inc. <br />27101 Puerta Real Suite 200 <br />Mission Viejo, CA 92691- <br />CPD -PIIC (01/07) <br />Policy Period From: 12/08/2013 To: 12/08/2014 at 12:01 AM. Standard Time at your mailing <br />address shown above <br />Business Description: Fitness Trainer <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE <br />AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS <br />PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />Commercial Property Coverage Part <br />Commercial General Liability Coverage Part $182.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Part <br />Commercial Auto Coverage Part <br />Commercial Stop Gap Part <br />Businessowners <br />Workers Compensation <br />Taxes /Fees /Surcharges $50.00 <br />Total $232.00 <br />FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE <br />Refer To Forms Schedule <br />*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />e6- " (D <br />Countersignature Date Authorized Representative <br />