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000uSign Envelope ID:uraou400'ons5-44 oFosos <br /> CERTIFICATE OF INSURANCE MAG Mutual Insurance Company <br /> Certificate issued to: <br /> Durham Regional Hospital <br /> Attn: Medical Staff Office <br /> 3G43 North Roxboro Rd <br /> Durham N(} 277O4-27O3 <br /> Name and mailing address of insured: <br /> Doin E. Vines, M.D. <br /> 400 Millstone Dr. <br /> Ste. 100 <br /> Hillsborough, North C8n]hOa 27278 <br /> This into certify that K4AG Mutual Insurance Company has issued a Medical Professional Liability Policy tnthe insured <br /> listed above, subject to the provisions to the current policy contract and any endorsements. <br /> Policy Number: Effective Date: Expiration Date: <br /> P8L 1701979 08 February 1, 2018 February 1' 2017 <br /> Limits <br /> Each loss/Aq91ftg&e linfit Retroactive Date: <br /> 1,008,000/3'000'000 04/00/2002 <br /> TOTAL LIMITS 1,000'000/3'000.000 <br /> This document is issued as a matter ofinformation only and confers no rights upon the document holder. This document <br /> does not amend, axtend, or alter the oovenaga, herme, oxo|usione, conditiona, or other provisions afforded by the policies <br /> referenced herein. <br /> 9|oaae inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation <br /> of the described policy, MAG Mutual will make reasonable effort to notify the party at vvhnne request this certificate was <br /> issued, but K8A8 Mutual shall not be liable in any way for failure to give such notice. <br /> W4AG Mutual Insurance Company <br /> P(] Box 52979 <br /> Atlanta, GA30355-097S <br /> Page 1 of <br /> CINS Ed.01/14 12/22/2U15 <br />