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Libertv- <br /> internat ion al <br /> Healthcare Professional Liability <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (A Stock Insurance Company,hereinafter the"Company") <br /> 55 Water Street, 18,h Floor <br /> New York,NY 10041 <br /> DECLARATIONS <br /> Policy Number: AHY-607461003 Renewal Of-* AHY-607461002 <br /> —--------- ...... <br /> SECTION I <br /> Item <br /> 1. Named Insured: Marth L Hadden MS,RN,CS <br /> Address:2. Add 112 Hanft Knoll, <br /> ------- <br /> Chapel Hill,NC 27514 <br /> ............... ........ <br /> 3. Policy Period: From: 05/01/2014 To: 05/01/2015 <br /> 12:01 A.M.Standard Time At Location of Designated Premises <br /> ................... ........................................... ......................... .................. ............................... <br /> 4. Business or Profession: Affiliation: 3534-ANA North Carolina Nurses Association <br /> CNS Adult <br /> 5. The Named Insured is a(n): ❑ Partnership-- ❑ Corporation Inlividual <br /> ❑ Sole Proprietor(with employees) ❑ Other. <br /> This 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(11/09),BCPL-203£;(11/09) <br /> HCPL-8020(Ed. 12/10), <br /> HCPL-3000(11/09), BCPL-2037-9000-NC(11/09)HCPL-3001(11/09)OFAC (08/09), <br /> SECTION II <br /> ---.---............. ............ .............................................. .................................... ............ <br /> Item COVERAGE Premiun <br /> A. Professional Liability 1XI $225.00 <br /> B. General Liability I I <br /> Terrorism Risk Insurance Act $0.00 <br /> C. Endorsements <br /> TOTAL: $225.00 <br /> .............. ............ ............... <br /> LIMITS OF LIABILITY <br /> ........................ ........... . ............... ................. ......... <br /> $2,000,000 Each Incident and Each Occurrence $4,000,000 gregate <br /> SECTION III <br /> SUPPLEMENTARY PAYMENTS <br /> A. First Party Assault <br /> B. Licensing Board Reimbursement <br /> C. Wage Loss and Expense <br /> D. Deposition Expense <br /> E. First Aid Reimbursement <br /> Representative Agent: Mercer Consumer,a service of <br /> Mercer Health&Benefits Administration LLC <br /> P.O.Box 14576 <br /> Des Moines,IA 50306-3576 <br /> 1-800-503-9230 <br /> HCPL-203 7D(11/09) <br />