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DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 <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 /> ................ <br /> Ref# Description Coverage Code Form No. Edition W..............u. <br /> P 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 /> mmimmm <br /> Limit 1 1. ........� Limit 2 ...........{....._.Limit 3 Deductible Amount Deductible Type Premium <br /> 1,000,000 <br /> I. .�........... <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 I <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 /> _._._ <br /> Limit 1..............._.mwmw Limit 2 Limit 3 Deductible Amount Deductible Type Premium,.W <br /> $824.00 <br /> Ref# 1 Description Coverage Code 1 Form No. Edition Date <br /> Experience Mod Factor 1 EXPO1 <br /> Limit 1 Limit 2 P Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# ...................................... ___...........__...............__....................................... ........... .......... _ _.'' <br /> Description <br /> on <br /> Terrorism _....... Coverage <br /> Code Form No. <br /> TERRO Edition Dat e <br /> Deductible Type Premium <br /> $757.00 <br /> 3 Deductible Amount <br /> Limit 1 Limit 2 ............... Limit � ..................... <br /> Ses ri Debit Coverage Code Form No. Edition Date <br /> P bit Modification SDM <br /> Ref#... .Descri do _ ............................ w <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> .......................... . . <br /> $12,479.00 <br /> Ref# 1 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............ .. ..�,-,,-..,,...... m____.m......-�....._... ,m._. ......- - .. .... -..-. <br /> 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $98.00 <br /> OFADTLCV Copyright 2001,AMS Services,Inc. <br />