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DocuSign Envelope ID:656DF690-72BC-42BC-9E47-7038084D8FFA <br /> Healthcare Professional Liability c%li # <br /> pig h ote natitzaaal <br /> Und r4,rat <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (1 Stock Insurance Company,hereinafter the"Company") <br /> 55 Water Street,18a 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-102357006 RENEWAL OF: AHX-102357005 <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: 06/01/2017 To: 06/01/2018 <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 /> $0.00 <br /> 6. Deductible(if applicable) $0 each Incident Total: $93.00 <br /> 7. The Named Insured is: N 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 STA'L'ED IN THE MAS'T'ER POLICY DECLARATIONS OR,IF <br /> APPLICABLE,AS ENDORSED HEREON <br /> This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and <br /> 9' 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 />