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DocuSign Envelope ID: 7D9491 BE-DD6D-4897-B77A-CD2FD6CC19A7 <br /> 110]nrerrcaticn�at <br /> �l'nderffeiecas, <br /> Healthcare Professional Liability <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (A Stock Insurance Company,hereinafter the Company) <br /> 55 Water Street, 18'h Fluor <br /> New York,NY 10041 <br /> DECLARATIONS <br /> Policy Number:AHY-768247001 Renewal Of:New <br /> SECTION I <br /> Item <br /> 1. Named Insured: Robert E.Dupuis <br /> 2. Mailing Address: clo NCAIA, <br /> PO Box 1165 <br /> Gary,NC 27512 <br /> 3. Policy Period: From: 12/22/2014 To: 12/22/2015 <br /> 12:01 A.M.Standard Time At Location of Designated Premises <br /> 4. Business or Profession: Affiliation: 3452-American Soc.of Health Sys.Pharmacists <br /> Pharmacist <br /> 5. The Named Insured is a(n): ❑Partnership ❑Corporation ®Individual ❑LLC <br /> aole etor es ❑aofessional Association❑other <br /> This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations <br /> and agreements contained in the following form(s)or endorsements(s): HCPL-20371(01114),HCPL-2038(11I09),HCPI 8101A(04114) <br /> HCPL-2037-9000-NC(11109)OFAC(08109) <br /> HCPL-8102(01)14), <br /> SECTION II <br /> Item COVERAGE Premium <br /> A. Professional Liability IX1 $117.00 <br /> 13. General Liability [ ] <br /> Terrorism Risk Insurance Act [ ] <br /> C. Endorsements j X1 $25.00 <br /> D. Risk Purchasing Group Fee $0.00 <br /> TOTAL: $142.00 <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. 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 Heaith&Benefits Administration LLC <br /> P.O.Box 14576 <br /> Des Moines,1A 50306-3576 <br /> HCPL-2037D (11109) <br />