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DocuSign Envelope ID: OF93300E -D182- 4824- AB97- AB4A8DFC99A5 <br />PO Box 469012 <br />San Antonio, TX 78246 <br />AR G O GROUP Email submissions to: am @colonyspecialty.com <br />Quote No: 174130 -1 Allied Medical Binder Confirmation <br />Date: 0312912017 <br />Optional Endorsements (included in the total premium above) <br />$2.500 <br />Deductible: <br />$50,00011 D0,000 <br />Legal Media Endorsement <br />SublimiE, <br />$0 <br />Premium: <br />Sublimit: <br />$50,000150,000 <br />Privacy Wrongful Acts <br />Premium: <br />$0 <br />Deductible: <br />$1,000 <br />Sublimit: <br />$50,000150,000 <br />Privacy Incident Response <br />$0 <br />Premium: <br />Deductible: <br />$1,000 <br />Sublimit: <br />$25,000125,000 <br />Evacuation Coverage <br />$0 <br />Premium: <br />Subjectivities <br />Binder is subject to receipt, review and acceptance of the following, within (10) la has carried similar coverages <br />binding: <br />�- Currently valued loss runs for any and all time during the past 5 years the applicant <br />(General Liability/Professianal Liability). Workers Compensation loss run is not acceptable- <br />- All applications included in the submission must be signed and dated by the applicant within 30 days prior to bind. <br />- Current State License. (All licenses provided are expired, except for facility located at 401 West Queen St) <br />- Completed, signed and dated No Know Loss Letter on insureds own letterhead (Copy Attached) <br />Business Description: <br />ASSISTED LIVING FACILITY FOR THE ELDERLY AND HOME HEALTH CARE AGENCY. <br />Audit Period: Annual <br />Minimum Earned: 25% Minimum Premium and Deposit: 100 1/4 <br />Forms <br />• GUPL <br />Access.or Disclosure of Confidential or Personal Info and Data - Related Liability (Ur-G2107-0916) - <br />Blanket Additional Insureds) - Mortgagees, Lenders, Lessors and/or Landlords (AP073ALMS 07 0711) <br />Certified Acts Of Terrorism -And Other Acts Of Terrorism Exclusion (AP041 LMS -0115) <br />Certified Acts of Terrorism and Other Acts of Terrorism Exclusion .(UCG2175- 0115) <br />Commercial General Liability Coverage part (LMSCGO002- 0912) <br />Common Policy Provisions (LMSCPP -0912) <br />Communicable Disease Exd (AP012LMS -0713) <br />Exclusion - Health Care Services and Patient Client or Resident Injury (AP051 NP -0912) <br />Exclusion - Recording and Distribution of Mat'l. or I nf. in Violation of Law (U983LM5- 0916) <br />Legal Media Endorsement (AP083- 0912) <br />Long Term Care Facilities - Common Dec, (LTCDEC -0713) <br />Medical Facility Barber And Beautician Services Coverage Extension (U57OLMS -0912) <br />Medical Facility Evacuation Coverage (AP097LMS -0912) <br />OFAC Advisory Notice OLP001 -0104) <br />Policyholder Disclosure - Notice of Terrorism Insurance Coverage (fRIANoticeA -0115) <br />Privacy Incident Response Cov (AP061 -1115) <br />Privacy Notice (PrivacyNodce -0415) <br />Privacy Wrongful Acts Sublimit (AP062LMS -0912) <br />Professional Liability Coverage Part (LMS0002.0912) <br />Punitive, Exemplary Or Multiple Damages Exclusion (AP070LMS -0912) <br />Risk Management Resource Center (RiskMgmtResCtr -0516) <br />