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DocuSign Envelope ID: B7DABF9A- D92E- 48BA- BCOB- AFFC399D4D85 <br />CERTIFICATE OF INSURANCE <br />Certificate issued to: <br />Blue Cross /Blue Shield - North Carolina <br />Attn: Credentialing <br />P.O. Box 2291 <br />Durham NC 27702 <br />Name and mailing address of insured: <br />Dain E. Vines, M.D. <br />400 Millstone Dr. <br />Ste. 100 <br />Hillsborough, North Carolina 27278 <br />MAG Mutual Insurance Com <br />This is to certify that MAG Mutual Insurance Company has issued a Medical Professional Liability Policy to the insured <br />listed above, subject to the provisions of the current policy contract and any endorsements. <br />Policy Number: <br />PSL 1701979 10 <br />TOTAL LIMITS <br />Effective Date: <br />February 1, 2018 <br />Limits <br />Each loss /Atigregate limit <br />1,000,000/3,000,000 <br />1,000,000/3,000,000 <br />Expiration Date: <br />February 1, 2019 <br />Retroactive Date: <br />04/09/2002 <br />This document is issued as a matter of information only and confers no rights upon the document holder. This document <br />does not amend, extend, or alter the coverage, terms, exclusions, conditions, or other provisions afforded by the policies <br />referenced herein. <br />Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event of cancellation <br />of the described policy, MAG Mutual will make reasonable effort to notify the party at whose request this certificate was <br />issued, but MAG Mutual shall not be liable in any way for failure to give such notice. <br />t f <br />Authorized Representative <br />MAG Mutual Insurance Company <br />PO Box 52979 <br />Atlanta, GA 30355 -0979 <br />Page 1 of 1 <br />CINS Ed. 01/14 INSURED 12/11/17 <br />