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Philadel 'phia Indemnity Insurance Company <br />& One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 <br />gazi—MA C01,4114010 POLICY DECI-4111;9QUS <br />fm UM7=4=111126 12101401001IR <br />Named Insured and Mailing Address: <br />Choc V Le <br />4 Fabriano <br />Irvine, CA 92620-2576 <br />Maguire Insurance Agency, Inc. <br />27101 Puerta Real Suite 200 <br />Wssion Viejo, CA 92691- <br />Policy Period From, 12/17/2015 To: 12/17/2016 at 12:01 AM, Standard Dme at your maHing <br />address shown above <br />Business Description: Fitness Trainer <br />Style/Art: Martial Arts <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 $122.00 <br />Commercial Crime Coverage Part <br />Commercial Inland Marine Coverage Pail <br />Commercial Auto Coverage Part <br />Commercial Stop Gap Part <br />Businessowners; <br />Workers Compensation <br />Taxes/Fees/Surcharges $50.00 <br />Total $172.00 <br />FORM (S) AND ENDORSEMENT (S) MADE A PART 6—FTHIS -POLICY AT T H I E TIME OF ISSUE_... <br />SSUE <br />Refer To Forms Schedule <br />*Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations <br />. . . . . ........ ... . . . ....... ...... . ...... ....... . <br />Countersignature Date Authorized Representative <br />