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EASTERN DENTISTS INSURANCE COMPANY <br /> (A Risk Retention Group) <br />PROFESSIONAL LIABILITY <br />DECLARATIONS PAGE <br />This policy is issued by your risk retention group. Your risk retention group may not be subject to all of <br />the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not <br />available for your risk retention group. <br />Policy Number: Broker ID: <br />Named Insured: <br />Mailing Address: <br />The Named Insured is: ____________________ <br />Policy Period: <br />Inception Date __________ to ____________ 12:01 AM standard time at the address of the named <br /> insured as stated herein. <br />Limits of Insurance: <br />$ each claim <br />$ annual aggregate <br />$ medical payments <br />Defense Coverages: <br /> Limits of Insurance: <br />Dental Prof. Liability Licensing Board <br />Sexual Misconduct <br />Health Information <br />Policy Form: Class: ________________________ . <br />THE INSURANCE AFFORDED IS ONLY WITH RESPECT TO THOSE COVERAGES LISTED <br />ITEM ANNUAL PREMIUM <br />Countersignature Date: __________________ By: __________________________ <br />At Westborough, Massachusetts <br />Worcester County Edward J. Carroll, Esq. <br />President and CEO <br />THIS IS NOT YOUR INVOICE. THE INVOICE IS ENCLOSED. <br />Acct. Mgr: Form Date: <br />NCO2202652-2652 <br />2022-08-11 18:37:38B <br />Monica Kim, DDS <br />702 Bradley Road <br />Chapel Hill, NC 27516 <br /> <br /> <br /> <br />SR01 <br />Sentinel Risk Advisors LLC <br />4700 Six Forks Road Suite 200 <br />Raleigh, NC 27609 <br />Individual <br />10/01/2022 10/01/2023 <br />1,000,000 <br />3,000,000 <br />5,000 <br />$50,000 each claim/$50,000 aggregate <br />Occurrence 1: Minimal Sedation or Less <br />Named Insured <br />Vicarious Liability (All) <br />Risk Management Discount <br />========= <br />TOTAL PREMIUM <br />08/11/2022 <br />Neil 09/01/2016 <br />DocuSign Envelope ID: DA4EEB72-3DF6-46DC-B719-740612113ADD