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DocuSign Envelope ID: D1DF359E-9612-459E-8293-F383F2149BD8 <br /> ADDITIONAL COVERAGES <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Terrorism TERRO <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $13.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Uninsured motorist combined single limit UMCSL <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> 1,000,000 $148.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Underinsured motorist combined single limit UNCSL <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> 1,000,000 $714.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> WCOT4 WCOT4 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Terrorism TERRO <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $429.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Sched Cr Modification SCM <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> -$14,593.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Catastrophe Oth Than Terr DTEC <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $961.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Experience Mod Factor 1 EXP01 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> $50,552.00 <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Experience Mod Factor 1 EXP01 <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> Ref# Description Coverage Code Form No. Edition Date <br /> Premium discount PDIS <br /> Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br /> -$14,316.00 <br /> OFADTLCV Copyright 2001,AMS Services,Inc. <br />