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DocuSign Envelope ID:89EE68A1-29FA-417C-9C6F-034CDOD2C779 <br /> PHILADELPHIA one Bala Plaza, Site 100 <br /> INSURANCE COMPANIES Bala Cynwyd, Pennsylvania 19004 <br /> 610.617.7900 Fax 610.617.7940 <br /> A Member of the l'okio\taring Group PHLY.com <br /> Philadelphia Indemnity Insurance Company <br /> COMMON POLICY DECLARATIONS <br /> Policy Number: PHPK1283261 <br /> Named Insured and Mailing Address: Producer: 16543 <br /> KAH Care, LLC. dba Right at Home Silverstone Group, Incorporated <br /> 9417 Collingdale Way 11516 Miracle Hills Dr Ste 100 <br /> Raleigh, NC 27617 Omaha, NE 68154 <br /> Policy Period From: 02/16/2015 To: 02/16/2016 at 12:01 A-M.Standard Time at your mail Ing <br /> address shown above. <br /> Business Description: Home Health Care Operation <br /> IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS <br /> POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br /> THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS <br /> INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br /> PREMIUM <br /> Commercial Property Coverage Part 100.00 <br /> Commercial General Liability Coverage Part 1,038.00 <br /> Commercial Crime Coverage Part 623.00 <br /> Commercial Inland Marine Coverage Part <br /> Commercial Auto Coverage Part 1,330.00 <br /> Businessowners <br /> Workers Compensation <br /> Professional Liability 2,546.00 <br /> Sexual/Physical Abuse INCLUDED <br /> Total ; 5,637.00 <br /> Total Includes Federal Terrorism Risk Insurance Act Coverage 3.00 <br /> FORM(S)AND ENDORSEMENT(S)MADE A PART OF THIS POLICY AT THE TIME OF ISSUE <br /> Refer To Forms Schedule <br /> 'Omits applicable Forms and Endorsements if shown in specific Coverage PartlCoverage Form Declarations <br /> CPO-PIIC(01107) <br /> Countersignature Date Authorized Representative <br />