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000uSign Envelope ID:uraou400'ons5-44 oFosos <br /> CERTIFICATE OF INSURANCE MAG Mutual Insurance Company <br /> Certificate issued to: <br /> Blue Cross/Blue Shield ' North Carolina <br /> Attn: Credentia|ing <br /> P.O. Box 2291 <br /> Durham NC277O2 <br /> Name and mailing address of insured: <br /> Dm\D E. Vines, M.D. <br /> 40O Millstone Dr. <br /> Ste. 100 <br /> Hillsborough, North Carolina 27278 <br /> This is to certify that K4AG Mutual Insurance Company has issued a Medical Professional Liability Policy tothe insured <br /> listed above, subject to the provisions to the current policy contract and any endorsements. <br /> Policy Number: Effective Date: Expiration Date: <br /> PSL 1701979 08 February 1' 2010 February 1, 2017 <br /> Limits <br /> Each loss/Ag,gregate limit Retroactive Date: <br /> 1'080'000/3'000'000 04/09/2002 <br /> TOTAL L|Q8|l[S 1'000'000/3'000'000 <br /> This document iaissued as matter ofinformation only and confers nu rights upon the document holder. This document <br /> does not amend, extend, or alter the coverage, terma, exclusions, oondiUone, or other provisions afforded by the policies <br /> referenced herein. <br /> Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation <br /> of the described policy, MAS Mutual will make reasonable effort to notify the party at whose request this certificate was <br /> issued, but MAG PWuiuo| shall not be liable in any way for failure to give such notice. <br /> K4AG Mutual Insurance Company <br /> P[> Box 52S78 <br /> Atlanta, GA30355'0Q7S <br /> Page 1v(1 <br /> 12/22/2015 C|NS Ed.O1/14 <br />