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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB Polley Number <br /> MY 1010647 <br /> Issued By: SELECTIVE INSURANCE COMPANY OF AMERICA <br /> 40 WANTAGE AVE, BRANCHVILLE, NJ 07890 <br /> PRIVATE COMPANY MANAGEMENT LIABILITY POLICY DECLARATIONS <br /> THE LIABILITY COVERAGES ON THIS POLICY ARE WRITTEN ON A CLAIMS-MADE BASIS. COVERAGE <br /> APPLIES TO CLAIMS FIRST MADE AGAINST INSUREDS DURING THE POLICY PERIOD OR EXTENDED <br /> REPORTING PERIOD. THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS OR JUDGMENTS WILL <br /> BE REDUCED BY DEFENSE COSTS, AND DEFENSE COSTS WILL BE APPLIED AGAINST THE RETENTION. <br /> REM 1. ITEM 2. <br /> Na •d and Address: Policy Period <br /> RALEIGH PATHOLOGY LABORATORY ASSOCIATES, PA / WAKE MEDICAL From: JUNE 15, 2017 <br /> LABORATORY CONSULTANTS, INC. <br /> PO BOX 14045 To: JUNE 15, 2018 <br /> RALEIGH, NC 27620-4045 12:01 A.M Standard Time At <br /> Named Entity Mailing Address. <br /> Producer Number: <br /> 00-07265-00000 <br /> Produ..r: SENTINEL RISK ADVISORS, LLC <br /> $ ITEM 3. <br /> All Notices Of Claim Or Loss Must Be Sent To The Insurer: Pursuant To The Terms Of This Policy In Writing To: <br /> SELECTIVE INSURANCE COMPANY OF AMERICA <br /> 40 WANTAGE AVE, BRANCHVILLE, NJ 07890 <br /> C vicenterlselectave.corn) <br /> ITEM 4. <br /> "X" Indicates Coverage Applies <br /> ® Part A—Private Company Directors, Officers And Entity Liability Premium <br /> Part B—Employment Practices Liability Premium <br /> 0 Part C—Fiduciary Liability Premium <br /> Part D—MLI ElitePac Premium <br /> TOTAL PREMIUM <br /> In return for pay nt of the premium, and subject to all to and conditions of policy, the Insurer agrees with the <br /> Insured to provide the ins , .Ence Indicated In schedules of these declarations. Insurance Is only • •vlded for those <br /> coverages when a specific limit is shown in the Declaration(s). <br /> Date Issued: APRIL 7, 2017 <br /> Issuing Office: SOUTHERN REGION <br /> A + •rized Representative: <br /> Copyright, 2013 Selective Insurance Company of America. All rights reserved. MY 00 10 04 13 <br /> Page 1 of 2 <br /> INSURED'S COPY <br />