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BUSINESS DESCRIPTION : Social Service Agency <br /> ALL PREMISES YOU OWN , RENT OR OCCUPY <br /> LOCATION NUMBER <br /> 001 1 AS PER SCHEDULE ON FILE WITH COMPANY <br /> CLASSIFICATION AND PREMIUM <br /> LINE OF CLASSIFICATION PREMIUM TRIA TOTAL INCEPTION <br /> COVERAGE PREMIUM <br /> PROFESSIONAL <br /> LIABILITY As per $ 10,326 $310 $ 10, 636 <br /> Supplemental <br /> COMMERCIAL <br /> GENERAL As per $35075 $93 $39168 <br /> LIABILITY Submission on <br /> file <br /> TOTAL INCEPTION PREMIUM <br /> $ 13,804 <br /> MINIMUM RETAINED PREMIUM $3,451 <br /> AUDIT PERIOD (IF APPLICABLE) ❑ ANNUALLY ❑ SEMI- ❑ QUARTERLY ❑ MONTHLY <br /> ANNUALLY <br /> ENDORSEMENTS <br /> ENDORSEMENTS ATTACHED TO THIS POLICY: <br /> SEE SCHEDULE OF APPLICABLE FORMS <br /> THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE <br /> FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE BO LIMBERED POLICY. <br /> Countersigned: By: <br /> 3118105 ( thon Representative) <br /> Page 2 of 2 © ISO Properties, Inc. , 2000 CG DS 01 10 01 11 <br />