EVANSTON INSURANCE COMPANY - - PRO …

1 MJIL10000810 Page1of1 ASTOCKCOMPANYINSURANCEPOLICYC overageaffordedbythispolicyisprovidedbyt heCompany(Insurer) ,thecompany(insurer)hascausedthispolicyt obeexecutedandattestedandcountersignedby adulyauthorizedrepresentativeofthecompan y(insurer) INSURANCE COMPANYTen Parkway NorthDeerfield, IL 60015 INTERLINEPRIVACY NOTICEWe are committed to safeguarding your privacy. We understand your concerns regarding the privacy of your nonpublic personal information. No nonpublic personal information is required to be collected when you visit our websites; however, this information may be requested in order to provide the products and services described.

2 We do not sell nonpublic per-sonal information to non-affiliated third parties for marketing or other purposes. We only use and share this type of infor-mation with non-affiliated third parties for the purposes of underwriting INSURANCE , administering your policy or claim and other purposes as permitted by law, such as disclosures to INSURANCE regulatory authorities or in response to legal pro-cess. Notwithstanding the foregoing, we may use this information for the purpose of marketing our own products and ser- vices to you. We collect nonpublic personal information about you from the following sources:Information we receive from you on applications or other forms;Information about your transactions with us, our affiliates, or others.

3 And/orInformation we receive from consumer reporting agencies and inspection do not disclose any nonpublic personal information about our customers/claimants or former customers/claimants to anyone, except as permitted by may disclose nonpublic personal information about you to the following types of third parties:Service providers, such as INSURANCE agents and/ or brokers and claims adjusters; and/or Other non-affiliated third parties as permitted by restrict access to nonpublic personal information about our customers/claimants to those individuals who need to know that information to provide products and services to our customers/claimants or as permitted by law.

4 We maintain physical, electronic, and procedural safeguards to guard your nonpublic personal of California:You may request to review and make corrections to recorded non-public personal information contained in our files. A more detailed description of your rights and practices regarding such information is available upon request. Please con-tact your agent/broker for instructions on how to submit a request to us. MPIL 1007 03 14 Page 1 of 1 HOW TO REPORT A CLAIMHow to report a new FAX:(855) 662-7535 *Phone:(800) 362-7535 Box 2009, Glen Allen, VA 23058-2009 If you have questions about a claim, please call may also be faxed to complete the appropriate ACORD form in detail and include the name and phone number of the contact person at the location of the reported incident.

5 If possible, please attach a copy of the facility incident report. When reporting an auto claim, please identify the unit # on the schedule along with the VIN#. If the loss/claim involves a building or damage to property, please provide the physical address of the property.*Please refer to your specific policy language for new claim reporting requirements. Some policies require you to report all claims in writing to send Supplemental Information / Questions on an existing 662-7535 Phone:(800) 362-7535 Box 2009, Glen Allen, VA 23058-2009 MPIL 1041 02 12 Page 1 of TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC")ADVISORY NOTICE TO POLICYHOLDERSNo coverage is provided by this Policyholder Notice nor can it be construed to replace any provisions of your policy.

6 You should read your policy and review your Declarations page for complete information on the coverages you are Notice provides information concerning possible impact on your INSURANCE coverage due to directives issued by OFAC. Please read this Notice Office of Foreign Assets Control (OFAC) administers and enforces sanctions policy, based on Presidential declarations of "national emergency". OFAC has identified and listed numerous:Foreign agents;Front organizations;Terrorists;Terrorist organizations; andNarcotics traffickers;as "Specially Designated Nationals and Blocked Persons".

7 This list can be located on the United States Treasury's web site accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this INSURANCE has violated sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this INSURANCE will be considered a blocked or frozen contract and all provisions of this INSURANCE are immediately subject to OFAC. When an INSURANCE policy is considered to be such a blocked or frozen contract, no payments nor premium refunds may be made without authorization from OFAC.

8 Other limitations on the premiums and payments also INSURANCE COMPANYMPIL 1083 04 15 Includes copyrighted material of INSURANCE Services Office, Inc. with its 1 of 1 MDIL 1000 08 11 Page 1 of 2 COMMON POLICY DECLARATIONSPOLICY NUMBER:RENEWAL OF POLICY:NamedInsuredandMailingAddress(No. ,Street,TownorCity,County,State,ZipCode) PolicyPeriod:Fromto,at12 :Annualunlessotherwisestated:FTZCode:THI S POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S), BUT ONLY FOR WHICH A PREMIUM ISINDICATED. THIS PREMIUM MAY BE SUBJECT TO Property Coverage Part$Commercial General Liability Coverage Part$Commercial Inland Marine Coverage Part$Commercial Ocean Marine Coverage Part$Commercial Professional Liability Coverage Part$Commercial Automobile Liability Coverage Part$Liquor Liability Coverage Part$$$$Premium Total$Other Charges:$$$$GRAND TOTAL$IndividualPartnershipLimitedLiabil ityCompanyOther Organization:BUSINESS DESCRIPTION:Other Coverages:Crime Coverage Part.

9 State Surplus Lines License #TerrorismCorporationTrustJoint VentureFORM OF BUSINESSIN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. EVANSTON INSURANCE COMPANY3DS54653DS5456 Participating Members of the WellnessPro Purchasing Group826 East State RoadSuite 100 American ForkUT8400312/01/201712/01/2018 Independent Distributor GroupXANNUALNOT COVEREDSeeBordereauNOT COVEREDNOT COVEREDNOT COVEREDNOT COVEREDNOT COVEREDNOT COVEREDNOT :By:DateAUTHORIZEDREPRESENTATIVEP roducerNumber,NameandMailingAddressInspe ctionOrdered:YesNoProgramCode:MDIL 1000 08 11 Page 2 of 2 These declarations, together with the Policy Conditions and Coverage Form(s) and any Endorsement(s), complete the above numbered policy.

10 74962 Citadel INSURANCE Services, LC826 E State Rd., Ste. 100 American ForkUT8400301/08/2018 BCFORMS SCHEDULEForm NumberForm NamePolicy Number:3DS5465 EVANSTON INSURANCE COMPANYF orms Applicable - INTERLINEMJIL 1000 08 10 POLICY JACKETMPIL 1007 03 14 PRIVACY NOTICEMPIL 1041 02 12 HOW TO REPORT A CLAIMMPIL 1083 04 15 TREASURY DEPT OFFICE OF FOREIGN ASSETS CONTROL NOTICEMDIL 1000 08 11 COMMON DECLARATIONSMDIL 1001 08 11 FORMS SCHEDULEIL 00 17 11 98 COMMON POLICY CONDITIONSMEIL 1200 10 16 SERVICE OF SUITF orms Applicable - GENERAL LIABILITYMDGL 1008 08 11 COMMERCIAL GL DECIL 00 21 09 08 NUCLEAR ENERGY LIAB EXCL ENDTMEIL 1225 10 11 CHANGES - CIVIL UNIONCG