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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB <br /> Previous Policy ts umber Policy Number <br /> S 1940885 S 1940885 <br /> - - <br /> SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA <br /> 3426 To it 1NCi DON WAY, ARLOTI°E,NC 28277 <br /> DECLARATIONS - COMMERCIAL UMBRELLA LIABILITY COVERAGE <br /> imm-One -Name of Insured & Mailing Address Policy Parket <br /> From: JUNE 7, 2017 <br /> SEE COMMERCIAL POLICY COMMON DECLARATION: IL-7025 <br /> .2 JUNI 7, 2010 <br /> 12°01 AMStndardTimeAtThc <br /> irrourer2 s M 41 Ad I I est. <br /> Producer: Producer Number: <br /> , SEE COMMERCIAL POLICY CO t DWLAPATION: IL-7025 00-07265-C,0000 <br /> ed Insured is: CORPORATION <br /> Business of the Named Insured: MEDICAL <br /> Limits Of lam cc <br /> Occurrence Limit $1,000,000.00 Aggregate LiMit $1,000, 000.00 <br /> Self Retained Limit: .00 <br /> ScImdite of Underlying Insurance and 1.; t'ts <br /> Standard EmOrsy Liability or Stopi4 4 • Policy No. W7227674 <br /> • - Li •••ity Pidicy <br /> C pony SELECTIVE INS CO OF AMERY <br /> Policy Period Eu ployers liability Each Accident $100,000 <br /> JUNE 7, 2017 Disease Each Employee $100,110i <br /> To: JUNE 7, 2018 Di Each Policy 8500,000 <br /> CommerciaJ G "ty Pa&y Piiey No. <br /> mm= <br /> 111.111111.1 <br /> C MEW <br /> ,VEM <br /> Policy Period General Agate <br /> ME7 F • Products-Completed •- aliens <br /> =111.01111m '10: 1VE:0 al and Advertising Injury Limit <br /> nn= <br /> plampo Each S urrence limit <br /> === <br /> Automobile Liability Policy Pdicy No. <br /> Compny <br /> Policy Pesiixt Bodily [Maly Pro, <br /> F . : • .1. Combined 4 Ii Act.; t <br /> To: <br /> P s i <br /> Estimated Exposure Bose Rate Rate Per Annual Minimum Pr ium Estimated Premium Due <br /> ht the event of cancellanon by the Named insured we will receive and retain not less than <br /> as the Policy Minimum • 'urn. <br /> Fo 5 and Endorsements: ritunated Total PICIAIIMI <br /> SEE FORMS AND ENDORSEMENT SCHEDULE: IL-7035 <br /> APRIL 21, 2017 SERVICE CENTER <br /> Issue Dale Issuing Office Authorized Representative <br /> C7X-0003 (01/99) INSURED'S COPY <br />