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allr.' <br /> N. 41 <br /> 111 <br /> . 1 <br /> ....., . <br /> Healthcare Professional Liability . .. <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (..,Stock Insurance Company,hereinafter the"'Company") <br /> 55 Water Street, 18111 Floor <br /> New York,NY 10041 <br /> DECLARATIONS <br /> Policy Number: AHY-564382001 Renewal Of: <br /> SECTION 1 <br /> I rein <br /> 1. Named insured: VIBEKE TALLEY <br /> 2. Mailing Address: 134 E TRYON ST, <br /> HILLSBOROUGH,NC 27278-2550 <br /> 3. Policy Period: From: 03/16/2012 To: 03/16/2013 <br /> 12:01 A.M.Standard Time At Location of Designated Premises <br /> 4. Business or Profession: Affiliation: American Occupational Therapy As,sn. <br /> Occupational Therapist <br /> 5. The Named Insured is a(n): Partnership Corporation X Individual <br /> Sole Proprietor(with employees) Other: <br /> Ibis policy is made and accepted subject to the printed conditions of this policy together with the provisions, <br /> stipulations and agreements contained in the following form(s)or endorsement(s): HCPL-2037(11109),HCPL-2038(11/09) <br /> HCPL-2151(11109), <br /> HCPL-2037-9000-NC(11/09)OFAC (08/09), <br /> SECTION II <br /> Item COVERAGE Premium <br /> A. Professional Liability MI $95.00 <br /> B. General Liability I I <br /> Terrorism Risk Insurance Act ( 1 $0.00 <br /> C. Endorsements I I <br /> TOTAL: $95.00 <br /> LIMITS OF LIABILITY <br /> $2,000,000 Each Incident and Each Occurrence $4,000,000 Aggregate <br /> SECTION III <br /> SUPPLEMENTARY PAYMENTS <br /> A. First Party Assault <br /> B. I.icensing Board Reimbursement <br /> C. Wage Loss and Expense <br /> D. Deposition Expense <br /> E. First Aid Reimbursement <br /> Representative Agent: Marsh U.S.Consumer <br /> a service of Scabury&Smith,Inc. <br /> P.O.Box 14576 <br /> Des Moines,IA 50306-3576 <br /> 1 111111 <br /> 1-800-5(13-9230 <br /> HCPL-2037D(11/09) <br />