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DocuSign Envelope ID:36527814-FF6E-473D-8780-375FBB508600 <br /> ow <br /> r <br /> s <br /> Vs . Liberty <br /> Surplus Insurance <br /> Real Estate Appraisers Professional Cororation,„ <br /> Liability <br /> Date Issued Policy Number Previous Policy Number <br /> 02/09/2015 LSI012905-002 LSI012905-001 <br /> LIBERTY SURPLUS INSURANCE CORPORATION <br /> (A New Hampshire Stock Insurance Company,hereinafter the"Company") <br /> 175 Berkeley Street <br /> Boston,MA 02117 <br /> THIS IS A CLAIMS MADE AND REPORTED POLICY. PLEASE READ IT CAREFULLY. <br /> Item DECLARATIONS <br /> 1. Customer ID: 167112 The insurance company with which this <br /> Named Insured: coverage has been placed is not licensed <br /> SMITH, DAVID ALLEN by the State of North Carolina and is not <br /> subject to its supervision. In the event of <br /> 3622 Lyckan Parkway the insolvency of the insurance company, <br /> Durham, NC 27705 losses under this policy will not be paid by <br /> any State insurance guaranty fund. <br /> 2. Policy Period: <br /> From: 01/27/2015 To: 01/27/2016 <br /> 12:01 A.M. Standard Time at the address stated in <br /> Item 1. <br /> 3. Deductible: $1,000 Each Claim <br /> 4. Retroactive Date: 01/27/2014 <br /> 5. Inception Date: 01/27/2014 <br /> 6. Limits of Liability: The Limit of Liability for Each Claim and in <br /> A. $500,000 Each Claim the Aggregate is reduced by Damages and <br /> B. $500,000 Aggregate Claims Expenses as defined in the Policy. <br /> 7. Mail all notices,including notice of claim,to Agent: <br /> LIA Administrators&Insurance Services <br /> 1600 Anacapa Street <br /> Santa Barbara,California 93101 <br /> (800)334-0652; Fax: (805)962-0652 <br /> 8. Annual Premium: $1,168.00 <br /> + $58.40 Surplus Lines Tax <br /> 9. Number of Appraisers: 1 <br /> 10. Forms attached at issue: LIA002S (10/11) LIA012 (08/11) LIA013 (08/11) LIA025 (03/10) <br /> OFAC (08/09) SC-9 (10/08) <br /> This Declarations Page together with the completed and signed Policy Application including all attachments and exhibits thereto, and the <br /> Real Estate Appraisers Professional Liability Insurance Policy shall constitute the -ct between the Named Insured and the Company. <br /> By <br /> LIAOO1S (04/10) Authorized Signature <br />