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Edition 04-2021 <br />RACE, NATIONAL ORIGIN & GENDER FORM <br />COMMUNITY SERVICE STATEMENT <br />•Form is to be included with delivery of new policy. <br />•Applicable to Individual or Partnership policyholders. Does not include Corporations, Joint Ventures, or other Non-individual <br />entity. <br />•The returned forms are stored in a manner that provides privacy to information contained in them. The forms are retained and <br />used to tabulate and prepare a report for the state of California. <br />This information is requested by the state of California in order to monitor the insurer’s compliance with the law. All new policyholders <br />are requested to voluntarily provide the following information. <br />No such information shall be used for purposes of underwriting or rating any policyholder. <br />Policyholder’s Name and Address (to be provided in order to refer back to the policy) <br />Policy Type: <br />If policyholder does not wish to provide the Department of Insurance with this information, please check here _____ <br />Check the Race or National Origin as it applies to the policyholder(s). For the purpose of completing this form, the policyholder is defined <br />as: an individual, spouse, domestic partner, or business partner(s) named on the policy. <br /> POLICYHOLDER CO-POLICYHOLDER <br /> Male Female Non-Binary Business Male Female Non-Binary Business <br />African-American _____ _____ _____ _____ _____ _____ _____ _____ <br />American Indian or Alaskan Native _____ _____ _____ _____ _____ _____ _____ _____ <br />Asian/Pacific Islander _____ _____ _____ _____ _____ _____ _____ _____ <br />Latino _____ _____ _____ _____ _____ _____ _____ _____ <br />White _____ _____ _____ _____ _____ _____ _____ _____ <br />Other _____ _____ _____ _____ _____ _____ _____ _____ <br />Completed forms are to be sent to: <br />biBERK <br /> PO Box 113247 <br />Stamford, CT 06911-3247 <br />biBERK Insurance Services <br />Policyholder Number : <br />This form is implemented to comply with California regulation 2646.6 and the California Statistical Analysis Bureau. <br />N9BP094899 <br />General Liability <br />Patricia Johnson <br />3516 20th Ave <br />Sacramento, CA, 95820 <br />EXHIBIT B <br />Docusign Envelope ID: 719DA141-AC44-83B6-8162-C79EED148CD3