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DocuSign Envelope ID:29F27D713-1E91-4DC9-92EB-7E7929E38DF6 <br /> l <br /> � <br /> LIA Adnxlllnlsrators & Insurance Services <br /> APPRAISAL AND VALUATION A S P E IN <br /> PROFESSIONAL LIABILITY INSURANCE POLICY <br /> DECLARATIONS <br /> ASPEN AMERICAN INSURANCE COMPANY <br /> (A stock insurance company herein called the"Company") <br /> 175 Capitol Blvd. Suite 100 <br /> Rocky Hill,CT 06067 <br /> Date Issued Policy Number Previous Policy Number <br /> 01/16/2019 AA1007922-04 AA1007922-03 71 <br /> THIS IS A CLAIMS MADE AND REPORTED POLICY. COVERAGE IS LIMITED TO LIABILITY FOR ONLY THOSE <br /> CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND THEN REPORT- <br /> ED TO THE COMPANY IN WRITING NO LATER THAN SIXTY(60)DAYS AFTER EXPIRATION OR TERMINATION <br /> OF THIS POLICY,OR DURING THE EXTENDED REPORTING PERIOD,IF APPLICABLE,FOR A WRONGFUL <br /> ACT COMMITTED ON OR AFTER THE RETROACTIVE DATE AND BEFORE THE END OF THE POLICY <br /> PERIOD. PLEASE READ THE POLICY CAREFULLY. <br /> Item <br /> 1.Customer ID: 167112 <br /> Named Insured: <br /> SMITH,DAVID ALLEN <br /> 3622 Lyckau Parkway <br /> Durham,NC 27705 <br /> 2.Policy Period: From: 01/27/2019 To: 01/27/2020 <br /> 12:01 A.M. Standard Time at the address stated in 1 above. <br /> 3.Deductible: $1,000 Each Claim <br /> 4.Retroactive Date: 01/27/2014 <br /> 5.Inception Date: 01/27/2016 <br /> 6.Limits of Liability: A. $500,000 Each Claim <br /> B. $500,000 Aggregate <br /> 7.Mail all notices, including notice of Claim,to: <br /> LIA Administrators& Insurance Services <br /> 1600 Anacapa Street <br /> Santa Barbara, California 93101 <br /> (800)334-0652; Fax: (805)962-0652 <br /> 8.Annual Premium: $925.00 <br /> 9. Forms attached at issue: LIA092(12/14) LIA NC(02116) LIA NC NOT(11/15) LIA012(12/14) <br /> LI-AO13(10/14) LIA025A(11/14) <br /> This Declarations Page,together with the completed and signed Policy Application including all attachments and exhibits thereto,and <br /> the Policy shall constitute the contract between the Named Insured and th any. <br /> 01/16/2019 By L� <br /> Date Authorized SigAature <br /> LIA-001 (12114) Aspen American Insurance Company <br />