Orange County NC Website
InsuredName:AdvancedDentalAssociatesInc. <br />PolicyNumber:Q971310636 <br />PolicyPeriod:06/02/2018to06/02/2019Page3of6 <br />ProcessedOn:03/19/2018(SeeReverseSide)47 <br />SupplementalDeclarations <br />Location1/Building1 <br />Address: <br />2CROSSWINDSESTATESDR <br />PITTSBORONC27312-8450 <br />County:Chatham <br />Occupancy/Operations: <br />EmploymentAgency <br />InterestofNamedInsuredInSuchPremises:Homeowner <br />Coverage DeductibleAmountofInsurance <br />PropertyProtection <br />1.BuildingsNIL <br />2.BusinessPersonalPropertyandPersonalPropertyofOthers <br />ReplacementCost <br />TheftExclusionApplies:No <br />PropertyDeductible$10,300 <br />3.IncomeProtection&ExtraExpenseActualLossSustained12Months <br />AutomaticAdjustmentofBusinessPersonalPropertyandPersonalPropertyofOthersCoverage–1% <br />PropertyandInlandMarine-OptionalCoverages: <br />SewerandDrainBackup$500$5,000 <br />UtilityProperties-DirectDamage$5,000 <br />ScheduleofStaticForms <br />FormNumberEditionDateDescription <br />/ <br />UPP01/10ULTRAPACKPLUSPOLICY <br />PK000109/17*ULTRAPACKPLUSCOMMERCIALPROPERTYCOVERAGEPART <br />PKAX01/10PRODUCTIONORPROCESSMACHINERY-DEDUCTIBLE <br />PKAY12/14SEWERANDDRAINBACK-UPCOVERAGE <br />PKBB07/16UTILITYPROPERTIES-DIRECTDAMAGE <br />CL020911/10IMPORTANTNOTICE-LEADLIABILITYEXCLUSION <br />CL021411/10*IMPORTANTNOTICE-POLICYSERVICEFEES <br />CL021812/15*IMPNOTICETOPROPINSPOLHLDR-NOFLOOD,EARTHQUAKE,MUDSLIDE, <br />MUDFLOW,LANDSLDE,WNDSTRM,HAILCOV <br />PKGP01/10AMENDMENTOFMOBILEEQUIPMENTDEFINITION <br />PKRE01/10NORTHCAROLINAAMENDATORYENDORSEMENT <br />PK000307/16ULTRAPACKPLUSEXTRALIABILITYCOVERAGES <br />CG000104/13COMMERCIALGENERALLIABILITYCOVERAGEFORM <br />CG009911/85CHANGESINGENERALLIABILITYFORMSFORCOMMERCIALPACKAGE <br />POLICIES <br />CG213811/85EXCLUSION-PERSONALANDADVERTISINGINJURY <br />CG214712/07EMPLOYMENT-RELATEDPRACTICESEXCLUSION <br />CG216712/04FUNGIORBACTERIAEXCLUSION <br />UFB21311/12*SUBSCRIBER'SAGREEMENT <br />CG217001/15CAPONLOSSESFROMCERTIFIEDACTSOFTERRORISM <br />CG219603/05SILICAORSILICA-RELATEDDUSTEXCLUSION <br />PKGN12/14PUNITIVEDAMAGESCOVERAGE <br />CL039601/17*IMPORTANTNOTICE-DATABREACHRESPONSEEXPENSESCOVERAGE <br />DocuSign Envelope ID: 9F2C2FF6-C184-4821-B124-5C284105DD0A