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Professional Insurance Exchange Mutual, Inc.


D-0000 POLICY NO.

Class II-H FIP

DECLARATIONS

1. NAME OF INSURED SCHEDULE

Individual Professional Liability Claims-Made Coverage

Keap
Addison Test 3
1507 E Blacklidge Drive
Tucson, Arizona 85719
USA

RETROACTIVE DATE

July 01 2023

2. A POLICY FROM July 01 2024 to July 01 2025 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-H

FIP

Each Claim

$2,000,000

Annual Aggregate

$6,000,000

Annual Premium

$300

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

Rate Type: Faculty

Quarterly Payment Schedule

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