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DocuSign Envelope ID: FE073E3E-A914-41CA-9713-D88EF600F829 <br /> Insured Name: Advanced Dental Associates Inc. <br /> Policy Number: Q971310636 <br /> Policv Period: 06/0212017 to 0610212018 Page 3 of 55 <br /> Supplemental Declarations <br /> Location 1 f Building 1 <br /> Address: Cccupancy]Operations: <br /> 2 CROSSWINDS ESTATES DR Employment Agency <br /> PITTSBORO NC 27312-8450 <br /> County: Chatham <br /> Interest of Named Insured In Such Premises: Homeowner <br /> Coverage Deductible Amount of Insurance <br /> Property Protection <br /> 1. Buildings NIL <br /> 2. Business Personal Property and Personal Property of Others Property Deductible $10,100 <br /> Replacement Cost <br /> Theft Exclusion Applies: No <br /> 3. Income Protection&Extra Expense Actual Lass Sustained 12 Months <br /> Automatic Adjustment of Business Persona[Property and Personal Property of Others Coverage —1% <br /> Property and inland Marine-Optional Coverages: <br /> Sewer and Drain Backup $500 $5,000 <br /> Utility Properties-Direct Damage $5,000 <br /> Schedule of Static Forms <br /> Form Number Edition Date description <br /> 1 <br /> LIP P, 01110 ULTRAPACK PLUS POLICY <br /> PK0001 02117 * ULTRAPACK PLUS COMMERCIAL PROPERTY COVERAGE PART <br /> PKAX 01110 PRODUCTION OR PROCESS MACHINERY- DEDUCTIBLE <br /> PKAY 12114 SEWER AND DRAIN BACK-UP COVERAGE <br /> PKBB 07/16 * UTILITY PROPERTIES - DIRECT DAMAGE <br /> CL0209 11110 IMPORTANT NOTICE -LEAD LIABILITY EXCLUSION <br /> CL0214 11110 * IMPORTANT NOTICE- POLICY SERVICE FEES <br /> CL0218 12115 * IMP NOTICE TO PROP INS POLHLDR-NO FLOOD, EARTHQUAKE, MUDSLIDE, <br /> MUDFLOW, LANDSLIDE, WNDSTRM, HAIL COV <br /> PKGP 01110 AMENDMENT OF MOBILE EQUIPMENT DEFINITION <br /> PKRE 01110 NORTH CAROLINA AMENDATORY ENDORSEMENT <br /> CL0459 07/16 * IMPORTANT NOTICE TO POLICYHOLDERS- ULTRAPACK PLUS PROGRAM <br /> PK0003 07116 * ULTRAPACK PLUS EXTRA LIABILITY COVERAGES <br /> CGO001 04113 COMMERCIAL GENERAL LIABILITY COVERAGE FORM <br /> CGO099 11/85 CHANGES IN GENERAL LIABILITY FORMS FOR COMMERCIAL PACKAGE <br /> POLICIES <br /> CG2138 11185 EXCLUSION - PERSONAL AND ADVERTISING INJURY <br /> CG2147 12107 EMPLOYMENT-RELATED PRACTICES EXCLUSION <br /> CG2167 12104 FUNGI OR BACTERIA EXCLUSION <br /> UFB213 11112 * SUBSCRIBER'S AGREEMENT <br /> CG2170 04115 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM <br /> CG2196 03105 SILICA OR SILICA-RELATED DUST EXCLUSION <br /> PKGN 12114 PUNITIVE DAMAGES COVERAGE <br /> Processed On:03119/2017 (See Reverse Side) <br />