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DocuSign Envelope ID: 30CC97DC-995F-48ED-9245-A640EBC3CAOC <br /> ..... . <br /> firstm. <br /> 1 South Wacker Drive, Suite 23:80 <br /> Chicago, IL 60668 <br /> 312-715-3010 <br /> UMBRELLA LIABILITY POLICY <br /> GENERAL DECLARATIONS <br /> Policy Number.: Nmsltoew3 oo Producer, Insurance Service C.Onter'of ikyettevill®;Ind <br /> Renevral'cif Policy Number.: New <br /> 1.. Named Insured: Wtwfda care LLe <br /> Mailing-Addr 5: 1312 H"15-WI(North <br /> Cha tt m CrossIng.Ste' <br /> cna�+w�tE too�x�i a <br /> 2.. Policy Period: Fmm,:.,i0%1.2014 To: 1016 ris <br /> 12:01 a.m. Lodi Time at Mailing Address Above <br /> 3. Annual Premium: w <br /> 4: Limits cif insurance and Retention: <br /> a. 1.000:400 Each Occurrence Limit <br /> b. 1Au3tl,t'W General Aggregate Limit <br /> c: 10.000 Retained Limit <br /> 5: Underlying:Policies and Limits: <br /> Co"raae Limits Irau r Torrri <br /> General t,pF>F►,ow lEacicoemaw" FkWNanprrWrAuance: 7 ,C <br /> ca�sy <br /> Liability 1ru8isx3i5 <br /> NPPli�032 3:oDQ,� �e�m��� <br /> Emptoyer s 500AW XAch Ao6dano 5tortcwoas! 7WZ14 <br /> Liability . <br /> W 100-009502 MOW /Dbo ea Poticy LwM <br /> Other alaiiity SMOW Miaeaea Each EmpkV" <br /> Additional Forms Applicable To This Policy At Issuance: <br /> Date:1019/2014 B �1 <br /> Authorized='Representative <br /> First Nora rofiUnsurar�e Gcamvany <br />