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DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 <br /> Insurance Group_ <br /> i <br /> RENEWAL OF POLICY <br /> COMMERCIAL UMBRELLA POLICY <br /> THESE DECLARATIONS TOG COMP WITH <br /> E THE COMON <br /> NUMB <br /> POLICY CONDITIONS AND COVERAGE ICY <br /> POLICY NUMBER: OD6-A005679-03 <br /> DECLARATIONS Agent <br /> Named Insured and Address (No., Street, Town, County, State) <br /> TRIANGLE UROLOGY ASSOCIATES, 190282000 MOORE & JOHNSON AGENCY <br /> ATTN: DAMN CL HANOVER CSC <br /> 205 FRASIER ST. PO BOX 17867 <br /> DURHAM, NC 27704 RALEIGH, NC 27619 <br /> Policy Period: (Month, Day, Year) <br /> From 06/25/2016 To 06/25/2017 <br /> 12:01 AM, standard time at the address of the Named Insured as stated herein. <br /> Form of Business: <br /> ❑ Individual ❑ Partnership IN Corporation Q Limited Liability Company <br /> ❑ Organization (Other than Partnership, Joint Venture, or Limited Liability Company <br /> Business Description: <br /> OFFICE. THIS POLICY, <br /> IN RETURN THE PAYMENT OF THE PREMIUM, AND SUBJECT WE AGREE WIDTH YOU TO PROVIDE THE INSURANCE AS STATED IN ALL OTHIS POLICY.RMHISOPREMIUM MAY <br /> BE SUBJECT TO AUDIT. <br /> Limit of Liability (Section III) $ 1,000,000 <br /> Each Occurrence Limit $ 1,000,000 <br /> General Aggregate Limit <br /> Product Completed Operations Aggregate Limit $ 1,000,000 <br /> Retained Limit Self-Insured Retention $ NIL <br /> Premium Computation Annual Premium $ 400.00 <br /> Advance Premium $ 400.00 <br /> Endorsements: <br /> CU2130 01/15 C112156 06/06 CU2136 01/15 473-0004 10/05 CU0004 05/09 473-0016 10/05 <br /> 473-0023 10/05 473-0040 10/05 473-0067 03/05 1L0017 11/98 473-0025 473-1125 02/09 CU2436 12/05 CU2150 0025 03/06 CU2186 05/14 <br /> PRE PAID - the total annual premium is due at inception. <br /> HANOCASH -the annual premium is payable according to the term of the Hanocash endorsement <br /> attachment <br /> —ACCOUNT BILL X DIRECT BILL Q Annual ❑ Semi-Annual ❑ Other <br /> Audit period: Non Auditable Unless indicated by 0 Annual Semi-Annual ❑ Other <br /> If you cancel this policy, we shall receive and retain not less than $ as a policy minimum <br /> premium. <br /> 473-1102 1108 <br /> 9,599 <br />