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DocuSign Envelope ID: FE073E3E-A914-41CA-9713-D88EF600F829 <br /> EriErie Insurance Exchange <br /> Erik Insurance <br /> Exchange <br /> Member • Erie Insurance Group <br /> 100 Erie Ins.PI. • Erie.PA 1653g <br /> Ultrapack Plus Policy Declarations <br /> Renewal Certificate <br /> Mailing Name and Address for insured: Other Interest: <br /> ADVANCED DENTAL ASSOCIATES <br /> INC <br /> 11312 US 15-501 NORTH <br /> STE 107-139 ' <br /> CHAPEL HILL NC 27517 <br /> 153636705 <br /> JJ1089 <br /> Named Insured's Full Name: <br /> Advanced Dental Associates Inc. <br /> Agent: Policy Period: Policy Number: <br /> JJ1095 THE SORGI INSURANCE AGENCY INC 06/02/2017 to 06/02/2018 Q971310636 <br /> Agent Address and Phone <br /> THE SORGI INSURANCE AGENCY INC Policy begins at 12:01 A.M. standard time on the <br /> 16 CONSULTANT PL STE 102 effective date and ends at 12.01 A.M. standard <br /> DURHAM NC 27707-6313 time on the expiration date. Standard time is <br /> 919-682-4814 determined at the stated address of the named <br /> insured. <br /> The insurance applies to those premises described below. This is subject to all applicable terms of the policy and <br /> attached forms and endorsements. <br /> Premium Summary <br /> Pay Plan Discount Applies <br /> Total Annual Policy Premium: $.348.00 <br /> (This is not a bill. Your invoice will follow in a separate mailing.) <br /> Property Protection -As Per Attached Supplemental Declarations <br /> Deductible (Property Protection Only) $500 <br /> Policy-Level Coverages <br /> Liability Protection Limits of Insurance <br /> Commercial General Liability Limits of Insurance <br /> Each Occurrence Limit $1,000,000 <br /> Damage to Premises Rented to You $1,000,000 Any One Premises <br /> Medical Expense limit $5,000 Any One Person <br /> Personal&Advertising Injury Limit Excluded <br /> General Aggregate Limit $2,000,000 <br /> Products/completed Operations Aggregate Limit $2,000,000 <br /> Processed On:03/19/2017 (See Reverse Side) <br />