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Professional Insurance Exchange Mutual, Inc.


D-2618 POLICY NO.

Class II-AP

DECLARATIONS

1. NAME OF INSURED SCHEDULE

Individual Professional Liability Claims-Made Coverage

JEREMY B. MAHONEY DMD LLC
JEREMY MAHONEY
8846 S Redwood Rd St N201
West Jordan, UT 84088
USA

RETROACTIVE DATE

June 13 2016

2. A POLICY FROM June 13 2026 to June 13 2027 12:01 a.m.

standard time issued to the Named Insured stated herein.

In consideration of the premium cited below and paid by the Insured, professional liability coverage is extended as indicated by specific premium charge or charges. The limit of the Company’s liability related to coverage extended shall be subject to all terms of the Policy referenced. Coverage applies to incidents occurring after the Retroactive Date listed and claims reported to the Company in writing by the insured or by claimants during the time period listed in #2 above.
COVERAGES LIMITS OF LIABILITY PREMIUM

Professional Liability Claims-Made Form

Class II-AP

Each Claim

$1,000,000

Annual Aggregate

$3,000,000

Annual Premium

$1,850

Authorized Signature CEO
Signature of David Alvord
David L. Alvord DDS

Rate Type: Standard

Annually Payment Schedule

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