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DocuSign Envelope ID:34046D39-94E5-43C6-BCAA-BF969263E26C r <br /> ii <br /> A ® <br /> R° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> �� 06/27/2017 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: <br /> HISCOX Inc PHONE <br /> (NC.No,Ext): (888)202-3007 (NC C,No): <br /> 520 Madison Avenue E-MAIL <br /> ADDRESS: contact@hiscox.com <br /> 32nd Floor INSURER(S)AFFORDING COVERAGE NAIC# <br /> New York,NY 10022 INSURER A: Hiscox Insurance Company Inc 10200 <br /> INSURED <br /> INSURER B: <br /> Silvia Lissette Saca INSURER C: <br /> 103 N.Crabtree Knoll INSURER D <br /> INSURER E: <br /> Chapel Hill NC 27514 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR - ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY), (MM/DD/YYYY) LIMITS <br /> COMMERCIAL GENERAL LIABILITY <br /> EACH OCCURRENCE _ $ <br /> DAMAGE TO RENED <br /> CLAIMS-MADE OCCUR <br /> PREMISES(Ea occur ence) $ _ <br /> MED EXP(Any one person) $ <br /> • <br /> PERSONAL&ADV INJURY $ <br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY PRO- <br /> JECT LOC <br /> PRODUCTS-COMP/OP AGG $ <br /> OTHER: — $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED — <br /> — <br /> AUTOS AUTOS BODILY INJURY(Per accident) $ <br /> HIRED AUTOS <br /> NON-OWNED PROPERTY DAMAGE <br /> AUTOS $ <br /> (Per accident) <br /> $ <br /> UMBRELLA LIAB _ OCCUR EACH OCCURRENCE _ $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION _ <br /> PER AND EMPLOYERS'LIABILITY Y/N STATUTE ERH <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBEREXCLUDED? N/A <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> Professional Liability Each Claim: $250,000 <br /> A UDC-1763911-E0-17 07/01/2017 07/01/2018 <br /> Aggregate: $ 250,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> si 60.-9,s <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />