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DocuSign Envelope ID:A4C13231-8323-41C4-8841-009EE8D11E71 <br /> ACQ" CERTIFICATE OF LIABILITY INSURANCE DA7E(MMIDDIYYYY) <br /> 06/28/2019 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsements). <br /> PRODUCER CONTACT <br /> NAMEi <br /> Hiscox Inc. PHONE {888)202-3007 ac NO: <br /> 520 Madison AvenueE-MAIL <br /> 32nd Floor ADD Es • contact@hiscox,cam <br /> New York,NY 10022 _ INSURERS AFFORDING COVERAGE NAIC0 <br /> INSURER A; Hiscox Insurance Company Inc 10200 <br /> INSURED INSURER B; <br /> Samar Shawa <br /> 2409 Silver Lake TH. INSURER C; <br /> Raleigh NC 27606 INSURERD., <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER- REVISION NUMBER: <br /> THIS i5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIR CLAIMS. <br /> INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS <br /> LTR POLICY NUMBER MMIDDfYYYY MMIOAfYYYY <br /> COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ <br /> DAMAGE—TGRENTED <br /> CLAIMS-MADE OCCUR _PREMISES(Ea occurrence $ <br /> ME EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ <br /> POLICY❑JEC LCIC PRCOUCTS-COMPIOPAGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COM9INED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Par accldent)AUTO $ <br /> H R 6S AUTOS <br /> AUTOS NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS Per accldent <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS UAB CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTIONS $ <br /> WORKERS COMPENSATION SEATUTE OTH- <br /> AND EMPLOYERS'LIABILITY Y f N <br /> ER <br /> ANYPROPRIETORIPARTNERIEXECUTIVE ❑ MIA <br /> El,EACH ACCIDENT $ <br /> OFFICE RIM EMBER EXCLUDED? <br /> (Mandatory In NH) E.L.DISEASE-EAEMPLOYE $ <br /> If yes,describe under <br /> ❑ESCRIPTI0N OF❑PERATIONS bell pW E.L DISEASE-POLICY LIMIT I$ <br /> A Professional Liability UDC-4203808-Ea-19 07/01/2019 07101/2020 Each Claim:$1,000,000 <br /> Aggregate:$1,000,000 <br /> DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (AC OR 1131,Additional Remarks Scheduto,may hn attached If more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> (D 1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACOR❑ <br />