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HCPL-2037D (11/09) <br />Healthcare Prof essional Liability <br />LIBERTY INSURANCE UNDERWRITERS INC. <br />(A Stock Insurance Company, hereinafter the “Company”) <br />55 Water Street, 18th Floor <br />New York, NY 10041 <br />DECLARATIONS <br />SECTION I <br />Item <br />1. Named Insured: <br />Mailing Address: <br />3. Policy Period: From:To: <br />12:01 A. M. Standard Time At Location of Designated Premises <br />4. Business or Profession:Affiliation: <br />5. The Named Insured is a(n): Partnership Corporation Individual LLC <br />Sole Proprietor (with employees) Professional Association Other <br />This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations <br />and agreements contained in the following form(s) or endorsements(s): <br />SECTION II <br />Item COVERAGE Premium <br />A. Professional Liability [ ] <br />B. General Liability [ ] <br />Terrorism Risk Insurance Act <br />C. Endorsements [ ] <br />TOTAL: <br />LIMITS OF LIABILITY <br />Each Incident and Each Occurrence Aggregate <br />SECTION III <br />SUPPLEMENTARY PAYMENTS <br />A. First Party Assault <br />B.Licensing Board Reimbursement <br />C. Wage Loss and Expense <br />D. Deposition Expense <br />E. First Aid Reimbursement <br />Representative Agent: <br />Policy Number: AHY-768247011 Renewal Of: AHY-768247010 <br />Robert E. Dupuis <br />c/o NCAIA <br />PO Box 1165 <br />Cary, NC 27512 <br />12/22/2024 12/22/2025 <br />Pharmacist <br />3452- American Soc. of Health Sys. Pharmacists <br />X <br />X $105.00 <br />X $25.00 <br />$130.00 <br />$2,000,000 $4,000,000 <br />AMBA <br />In CA dba Assn Member Benefits & Insurance Agency <br />P.O. Box 14554 <br />Des Moines, IA 50306 <br />HCPL-2037i (01/14), HCPL-2038 (11/09), HCPL-8101A (04/14) <br />HCPL-2037-9000-NC (11/09) <br />ADM-OFAC-0419, HCPL-8103 (05/15), <br />HCPL-8320 (01/15), HCPL-8321 (01/15), HCPL-8324 (01/15), HCPL-8328 (02/15) <br />Docusign Envelope ID: F1B6D46E-B6F4-46B7-A7DE-F4008698951A