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SAGITTA 25.3 (2016/03) <br />DESCRIPTIONS (Continued from Page 1) <br />Form Information <br />Form Description: Sexual Acts Liability Endorsement Limit1 : 1,000,000 <br />Ded.#1: $5,000.00 Limit2: 2,000,000 <br />** Workers Comp Information ** <br />Other States Coverage <br />Proprietors/Partners/Executive Officers/Members Excluded: <br />Ann Burton, Officer <br />Dave Wilkerson, Officer <br />Residual Market Limited Other States Insurance Endorsement <br />Included States:NE,NV,NH,NJ,NM,NY,NC,OK,PA,RI,SC,SD,TN,TX,UT <br /> VT,VA,WV,WI <br />** Supplemental Name ** <br />First Supplemental Name applies to all policies - Name Printed on DEC Page: Senior Care of Orange County Inc. <br />DBA Soltys Place <br />Orange County, its officers, agents and employees are to be designated as additional insured with respect <br />to the general liability policy. <br />2 of 2 <br />#S37471585/M37471582 <br />Docusign Envelope ID: 9BEB80A6-4CE4-4031-8FC2-8B9B7FF17793