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Markel Insurance Company <br />AIIW POLICY NUMBER: MTU70002501-00 F-XCESSNMBRELLA <br />PREVIOUS POLICY NUMBER: NEW MD 067 -FL 08 03 <br />EXCESS/UMBRELLA DECLARATIONS <br />yarned Insured and Mailing AOdress: Agent's Named and Mailing Address: <br />Coastal Health Systems of Brevard Inc Cindy Elbert Insurance Services <br />485 Gus Hipp Blvd. 15182 N 75th Ave #100 <br />Rockledge, FL 32955 Peoria, AZ 85381 <br />ProducerNumber' AZ15070K <br />�cIE Period From: 5/27/13 TO: 5/27/14 <br />Al 12:01 a.m. standard time at your mailing address she" above <br />"his policy provides Excess Lability coverage only or Umbrella Liability coveraoe c <br />Only the pokey provisions applicable to the type of coverage checked in the aboue box will apply. Please <br />refer to the approprWte sections of the policy for what is and is not covered according to the coverage�t pft <br />In return for the payment of the premium and subject to all the terms of this parity, we agree to provide the insurance as <br />stated in this policy. <br />Policy Premium: $1B, 595.00 <br />Direct Billed A22ncy Billed <br />Limps of Insurance: <br />General Aggregate $ 1,000,000 <br />Products -Completed Operations Aggregate $ 1,000,000 <br />Each Occurrence $ 1, 00D, 000 <br />Each Person— Personal and Advertising Injury $ 1,000,000 <br />Self Insured Retention -- Each Occurrence $ 10,000 <br />Forms and Endorsements attached to this policy at time of issuance: <br />SEE SCHEDULE OF FORMS AND ENDORSEMENTS <br />Issue Date: May 31, 2013 At: Kennesaw, GA By: Greg Thompson <br />(Authorized Representative) <br />MD 067 -FL 08 03 Copyright, Markel Insurance Comparry, 2003 page 1 of 4 <br />90 <br />