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DocuSign Envelope ID:90CC09F4-5057-4B 1 F-AC03-CF23967BA7A0 <br /> S <br /> 4' "a' <br /> t s__ <br /> Healthcare Professional Liability <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (A Stock Insurance Company,hereinafter the Company) <br /> 55 Water Street, 18th Floor <br /> New York,NY 10041 <br /> DECLARATIONS <br /> Policy Number: AHY-768247003 Renewal Of: AHY-768247002 <br /> SECTION I <br /> Item <br /> 1. Named Insured: Robert E. Dupuis <br /> 2. Mailing Address: c/o NCAIA, <br /> PO Box 1165 <br /> Cary, NC 27512 <br /> 3. Policy Period: From: 12/22/2016 To: 12/22/2017 <br /> 12:01 A. M. Standard Time At Location of Designated Premises <br /> 4. Business or Profession: Affiliation: 3452-American Soc. of Health Sys. Pharmacists <br /> Pharmacist <br /> 5. The Named Insured is a(n): Partnership ❑Corporation ®Individual ❑LLC <br /> USole Proprietor (with employees) ❑Professional Association❑Other <br /> This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations <br /> and agreements contained in the following form(s) or endorsements(s): HCPL-20371(01/14),HCPL-2038(11/09),HCPL-8101A(04114) <br /> HCPL-2037-9000-NC (11/09)OFAC (08/09) <br /> HCPL-8103(05/15), <br /> HCPL-8320(01/15),HCPL-8321(01115),HCPL-8324(01/15),HCPL-8328(02/15) <br /> SECTION II <br /> Item COVERAGE Premium <br /> A. Professional Liability I X1 $105.00 <br /> B. General Liability I I <br /> Terrorism Risk Insurance Act [ ] <br /> C. Endorsements [X] $25.00 <br /> U. Risk Purchasing Group Fee $0.00 <br /> TOTAL: $130.00 <br /> LIMITS OF LIABILITY <br /> $2,000,000 Each Incident and Each Occurrence $4,000,000 Aggregate <br /> SECTION III <br /> SUPPLEMENTARY PAYMENTS <br /> A. First Party Assault <br /> B. Licensing Board Reimbursement <br /> C. Wage Loss and Expense <br /> D. Deposition Expense <br /> E. First Aid Reimbursement <br /> Representative Agent: Mercer Consumer,a service of <br /> Mercer Health&Benefits Administration LLC <br /> P.U.Box 14576 <br /> 1 El Des Moines,IA 50306-3576 <br /> HCPL-2037D (11/09) <br />