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Capitol Specialty Insurance Corporation POLICY CHANGE SUMMARY <br /> P.O. Box 5900, Madison, WI 53705 <br /> POLICY NUMBER POLICY PERIOD AGENCY/PRODUCER CODE <br /> PR03027746-01 10/06/2020 - 10/06/2021 4692P <br /> 12:01 A.M. Standard Time at the address <br /> of the insured stated herein. <br /> NAMED INSURED AND ADDRESS AGENCY/PRODUCER <br /> Aura Creative Inc Pacific International Underwriters, Inc. <br /> DBA Aura Art& Ink; DBA Clorae.Baca.Photography PO Box 2007 <br /> 14002 NE 181st PI Edmonds WA 98020-9507 <br /> Apt A302 <br /> Woodinville, WA 98072-8538 <br /> CHANGE#: 002 <br /> EFFECTIVE DATE OF CHANGE: 10/13/2020 <br /> $50.00 Additional Annual Premium $50.00 Additional Premium Due <br /> $0.00 Annual Return Premium $0.00 Return Premium Due <br /> No Change In Premium 0.981 Pro Rate Factor <br /> Short Rate Factor <br /> BELOW IS A SUMMARY OF THE CHANGES EFFECTIVE AS OF THE DATE SET FORTH ABOVE IN THIS POLICY <br /> CHANGE SUMMARY: <br /> Added the following as additional insured on form CG2026: <br /> City of Everett <br /> 2930 Wetmore Ave <br /> Everett, WA 98201 <br /> PLEASE READ YOUR POLICY IN ITS ENTIRETY FOR ALL TERMS AND CONDITIONS. THIS POLICY CHANGE <br /> SUMMARY DOES NOT MODIFY OR ALTER ANY OF THE TERMS OR CONDITIONS OF THIS POLICY. <br /> Countersigned 10/13/2020 By 1A(? " <br /> Authorized Representative <br /> Additional Premium: $50.00 <br /> Additional State Tax: $1.00 This contract is registered and delivered as a <br /> Additional Stamping Fee: $0.05 surplus line coverage under the insurance <br /> code of the state of Washington,Title 48 RCW. <br /> Total Additional: $51.05 It is not protected by any Washington state <br /> guaranty association law. <br /> Pacific International Underwriters,Inc. <br /> CICG 349(01-11) Page 1 of 1 <br />