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DocuSign Envelope ID:4250E623-7DB7-4E1C-AF70-81 C64E3C944F <br /> CERTIFICATE OF LIABILITY INSURANCE DATE: 04/27/2016 <br /> PRODUCER: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY <br /> AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE <br /> AFFORDED BY THE POLICIES BELOW. <br /> INSURED: JENNIFER CRISP,DDS INSURERS AFFORDING COVERAGE <br /> 3154 S CHURCH ST INSURER A: The Medical Protective Company <br /> BURLINGTON,NC 27215 5814 Reed Road,Fort Wayne,IN 46835 <br /> NAIC number-11843;www.medpro.com <br /> Specialty:GENERAL DENTIST <br /> COVERAGES <br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. <br /> NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE <br /> MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND <br /> CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE POLICY POLICY POLICY LIMITS <br /> LTR NUMBER EFFECTIVE EXPIRATION <br /> DATE DATE <br /> (MM/DD/YY) (MM/DD/YY) <br /> GENERAL LIABILITY EACH OCCURRENCE $ <br /> ❑COMMERCIAL GENERAL LIABILITY PER CLAIM $ <br /> ❑ CLAIMS MADE ❑OCCUR FIRE DAMAGE(Any one fire) $ <br /> ❑ MED EXP(Any one person) $ <br /> ❑ PERSONAL&ADV INJURY $ <br /> GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> ❑ POLICY❑ PROJECT❑ LOC PRODUCTS-COMP/OP AGG $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> ❑ANY AUTO (Each accident) $ <br /> ❑ALL OWNED AUTOS BODILY INJURY <br /> ❑ SCHEDULED AUTOS (Per person) $ <br /> ❑ HIRED AUTOS BODILY INJURY <br /> ❑ NON-OWNED AUTOS (Per accident) $ <br /> ❑ PROPERTY DAMAGE <br /> (Per accident) $ <br /> PROFESSIONAL LIABILITY 805610 07/01/2016 07/01/2017 PER OCCURRENCE $ 1,000,000 <br /> LI OCCURRENCE PER CLAIM $ <br /> ❑ CLAIMS MADE <br /> RETRO DATE: ANNUAL AGGREGATE $ 3,000,000 <br /> EXCESS LIABILITY EACH OCCURRENCE $ <br /> ❑ OCCURRENCE I=1 CLAIMS MADE AGGREGATE $ <br /> ❑ DEDUCTIBLE $ <br /> ❑ RETENTION $ $ <br /> WORKERS COMPENSATION AND ❑WC STATUTORY LIMITS ❑ OTHER <br /> EMPLOYER'S LIABILITY E.L.EA ACCIDENT $ <br /> E.L.DISEASE-EA EMPLOYEE $ <br /> E.L.DISEASE-POLICY LIMIT $ <br /> OTHER: PER OCCURRENCE LIMIT <br /> EMPLOYMENT PRACTICES LIABILITY OF DEFENSE $ <br /> DEFENSE COVERAGE AGGREGATE LIMIT OF <br /> RETRO DATE: DEFENSE $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SEE POLICY FOR SPECIFIC COVERAGE INFORMATION/SPECIAL PROVISIONS <br /> CERTIFICATE HOLDER: CANCELLATION <br /> JENNIFER CRISP,DDS THE MEDICAL PROTECTIVE COMPANY WILL NOT <br /> 3154 S CHURCH ST BE RESPONSIBLE FOR INFORMING THE <br /> BURLINGTON,NC 27215 CERTIFICATE HOLDER OF ANY CHANGES IN <br /> COVERAGE OR IN THE LIMITS OF LIABILITY OR IN <br /> THE EVENT OF THE TERMINATION OR <br /> CANCELLATION OF THE POLICY. <br /> The Medical Protective Company Representative <br /> COI 1000 01/11 <br />