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DocuSign Envelope ID:0182CE2A-782E-419C-BBAF-41AC529B06BF <br /> ADDITIONAL COVERAGES <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Uninsured motorist combined single limit UMCSL <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> 1,000,000 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Underinsured motorist combined single limit UNCSL <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> 1,000,000 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Terrorism TERRO <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $757.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> WCOT4 WCOT4 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Experience Mod Factor 1 EXPO1 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $824.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Experience Mod Factor 1 EXPO1 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Terrorism TERRO <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $757.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Sched Debit Modification SDM <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $12,479.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Premium discount PDIS <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> -$10,141.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Increased employer's liability INEL <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $98.00 <br /> OFADTLCV Copyright 2001,AMS Services,Inc. <br />