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DocuSign Envelope ID:49BCBA8C-0E7D-4617-A6F3-B8BEO1DA708F <br /> Liberty_ <br /> rs <br /> , <br /> Healthcare Professional Liability <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (A Stock hisurance Company,hereinafter the Company ) <br /> 55 Water Street, 18th Floor <br /> New York, NY 10041 <br /> DECLARATIONS <br /> Policy Number:AHY-768247002 Renewal Of:AHY-768247001 <br /> SECTION I <br /> Item <br /> 1. Named Insured: Robert E. Dupuis <br /> 2. Mailing Address: do NCAIA, <br /> PO Box 1165 <br /> Cary, NC 27512 <br /> 3. Policy Period: From: 12/22/2015 To: 12/22/2016 <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): DPartnership C3 Corporation 12g Individual 1:ILLC <br /> ElSole Proprietor (with employees) D Professional Association LI 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-2037i(01/14),HCPL-2038(11/09),HCPL-8101A(04/14) <br /> HCPL-2037-9000-NC(11/09)OFAC(08/09) <br /> HCPL-8103(05/15), <br /> HCPL-8320(01/15),HCPL-8321 (01/15),HCPL-8324 (01/15),HCPL-8328(02/15) <br /> SECTION II <br /> Item COVERAGE Premium <br /> A. Professional Liability [XI $99.00 <br /> B. General Liability <br /> Terrorism Risk Insurance Act [ ] <br /> C. Endorsements [X] $25.00 <br /> D. Risk Purchasing Group Fee $0.00 <br /> TOTAL: $124.00 <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 Health&Benefits Administration LLC <br /> P.O.Box 14576 <br /> 111 Des Moines,IA 50306-3576 <br /> HCPL-2037D (11/09) <br />