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DocuSign Envelope ID: 11 591086-0989-4E2D-8A03-5E4CDBBE1 178 <br />ADDITIONAL COVERAGES <br />Ref # <br />Description <br />Uninsured motorist property damage <br />Coverage Code <br />UMPD <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />100 <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Uninsured motorist combined single limit <br />Coverage Code <br />UMCSL <br />Form No. <br />Edition Date <br />Limit 1 <br />1,000,000 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Underinsured motorist combined single limit <br />Coverage Code <br />UNCSL <br />Form No. <br />Edition Date <br />Limit 1 <br />1,000,000 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Personal & Advertising Injury <br />Coverage Code <br />PIADV <br />Form No. <br />Edition Date <br />Limit 1 <br />2,000,000 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Umbrella(C) <br />Coverage Code <br />CUMBR <br />Form No. <br />Edition Date <br />Limit 1 <br />2,000,000 <br />Limit 2 <br />2,000,000 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Adjst. to reconcile -exp mod. premium <br />Coverage Code <br />AREM <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />- $1,009.00 <br />Ref # <br />Description <br />Premium discount <br />Coverage Code <br />PDIS <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />- $300.00 <br />Ref # <br />Description <br />Schedule rate adjustment <br />Coverage Code <br />SRA <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />- $980.00 <br />Ref # <br />Description <br />Schedule rate adjustment <br />Coverage Code <br />SRA <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />-$1,542.00 <br />Ref # <br />Description <br />Premium discount <br />Coverage Code <br />PDIS <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />- $473.00 <br />Ref # <br />Description <br />WC & Employer's liability <br />Coverage Code <br />WCEL <br />Form No. <br />Edition Date <br />Limit 1 <br />1,000,000 <br />Limit 2 <br />1,000,000 <br />Limit 3 <br />1,000,000 <br />Deductible Amount <br />Deductible Type <br />Premium <br />OFADTLCV Copyright 2001, AMS Services, Inc. <br />