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Professional Insurance Exchange Mutual, Inc.


D-0960 POLICY NO.

Class II-AP

DECLARATIONS

1. NAME OF INSURED SCHEDULE

Individual Professional Liability Claims-Made Coverage

Summit View Dental & Wellness
John Myers
13304 S. LAKE FOREST DRIVE.
DRAPER, UT 84020
USA

RETROACTIVE DATE

February 27 2007

2. A POLICY FROM February 27 2026 to February 27 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

$2,298

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

Rate Type: Standard

Quarterly Payment Schedule

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