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DocuSign Envelope ID:3E6B5F62-1B34-4EFO-B839-959030955648 <br /> Healthcare Professional Liability <br /> \ �r .ibex` ' <br /> es International <br /> tlnden■riters. <br /> LIBERTY INSURANCE UNDER WRITERS INC. <br /> (A Stock Insurance Company,hereinafter the"Company") <br /> 55 Water Street,18th Floor <br /> New York,NY 10041 <br /> CERTIFICATE OF INSURANCE <br /> HEALTHCARE PROFESSIONAL LIABILITY <br /> CLAIMS-MADE INSURANCE POLICY FOR MEMBERS OF THE FEDERATION <br /> Item CERTIFICATE NUMBER: AHX-102357005 RENEWAL OF: AHX-102357004 <br /> 1. NAMED INSURED Lorraine Lewis <br /> 2. MAILING ADDRESS 107 Morningside Drive <br /> Carrboro,NC 27510-1254 <br /> 3 Policy Period 12:01 A.M.Standard Time From: 06/01/2016 To: 06/01/2017 <br /> At Location of Designated Premises <br /> 4. Prior Acts Date: 06/13/1993 <br /> 5. COVERAGE LIMITS OF LIABILITY PREMIUM <br /> Professional Liability $1,000,000 each Incident $3,000,000 Aggregate $93.00 <br /> Terrorism Risk Insurance Act $0.00 <br /> 6. Deductible(if applicable) $0 each Incident Total: $93.00 <br /> 7. The Named Insured is: Sole Proprietor(including Independent Contractors) ❑Partnership ❑ Corporation <br /> ❑ Other: Affiliation: 3410-Trager Approach Prof.Liability <br /> 8 Business or Occupation of the Named Insured:AS STATED IN THE MAS"1'ER POLICY DECLARATIONS OR,IF <br /> APPLICABLE,AS ENDORSED HEREON <br /> 9. <br /> This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and <br /> agreements contained in the following form(s) or endorsement(s): <br /> HCPL-2026(11/09),HCPL-2038(11/09),HCPL-8002(11/09),HCPL-8004(11/09) <br /> HCPL-8005(11/09),HCPL-8086(12/10),HCPL-8001 (11/09), <br /> OFAC (08/09),HCPL-2026-9000-NC(4/10) <br /> REPRESENTATIVE: <br /> Mercer Consumer,a service of <br /> Agent: Mercer Health&Benefits Administration LLC <br /> Office Address: P.O,Box 14576 <br /> Des Moines,IA 50306-3576 <br /> 1 <br /> HCPL-2026D (11/09) <br />