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DocuSign Envelope ID: 3D9A2C3C-B477-4E3B-886F-5583C52FF19A <br /> Change Date: 11/11/2015 PI-HS-003D (07/04) <br /> PHILADELPHIA INDEMNITY INSURANCE COMPANY <br /> HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE PART <br /> DECLARATIONS <br /> POLICY NO. PHPK1396797 Effective Date: 09/15/2015 <br /> 12:01 A.M. Standard Time <br /> LIMITS OF INSURANCE <br /> AGGREGATE LIMIT 3,000,000 <br /> EACH PROFESSIONAL INCIDENT LIMIT 1,000,000 <br /> BUSINESS DESCRIPTION <br /> Form of Business: CORPORATION <br /> Business Description: Non Profit Organization <br /> PREMIUM: $ 1,495.00 <br /> FORMS AND ENDORSEMENTS (Other than Applicable Forms and Endorsements Shown Elsewhere in the Policy) <br /> Forms and Endorsements Applying to this Coverage Part and Made Part of this Policy at Time of Issue: <br /> SEE SCHEDULE <br /> THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. <br /> Includes Copyrighted Material of the Insurance Service Office, Inc Used with its Permission, <br /> Page I of 1 <br />