Policy Declaration2

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Professional Insurance Exchange Mutual, Inc.


policy-declaration2 POLICY NO.

Class ii-H FIP

DECLARATIONS

1. NAME OF INSURED SCHEDULE

Individual Professional Liability Claims-Made Coverage

Ashley Zufelt Dentistry

Ashley Zufelt

street

city, state zip

usa

RETROACTIVE DATE

jan 1, 2000

2. A POLICY FROM dec 20, 2023 to dec 20, 2024 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

$1,000,000

Annual Aggregate

$3,000,000

Annual Premium

$1,300

Authorized Signature CEO

Signature of David Alvord

David L. Alvord DDS

Rate Type: Faculty

annual Payment Schedule

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