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t <br />HISCOX <br />Effective With UNDERWRITERS AT LLOYD'S, LONDON <br />Administered by Hiscox Inc. <br />520 Madison Avenue 32i° Floor, New York, NY 10022 <br />(648) 462-2353 <br />Insurance for Allied Healthcare Professionals <br />DECLARATIONS <br />THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS ONES LAW. PERSONS INSURED BY SURPLUS LINES <br />CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT OF ANY <br />RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNUCENSED INSURER. <br />SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT <br />APPROVED BY ANY FLORIDA REGULATORY AGENCY. <br />Broker No.: US 0000114 American Professional Liability Underwriters <br />Inc (Gabor Insurance) <br />Certificate No.: ME01505401.14 7270 NW 12th St Ste 700 ROM^a ITEM GABOR <br />7770 tm 12STREET <br />Renewal of: NEW Miami, FL 33126-1929 'WitRD IA33s <br />m�HAanamAaun <br />SWUM IDCS AGENT • A00IM7 <br />PROCIUMG ABM <br />1. Named Insured: <br />Address: <br />2. Policy Period: <br />3. General terms and <br />conditions wording: <br />Indian River Healthy Start Coalition Inc & Healthy Families of Indian River <br />33317th St Ste 2R <br />Vero Beach, FL 32960-7100 <br />JACKIE SAVELL <br />ST ROYAL PALM PONTE <br />VENO BEACH, FL 32960 <br />Inception Date: 11/04/2014 Expiration Date: 11/04/2015 <br />Inception date shown shall be at 12:01 A.M. (Standard Time) to Expiration date shown above at <br />12:01 A.M. (Standard Time) at the address of the Named Insured. <br />WCL P0001 CW (05/13) <br />The General terms and conditions apply to this policy in conjunction with the specific wording <br />detailed in each section below. <br />4. Endorsements: E6002.1 - Florida Amendatory Endorsement, E6015.2 - Lloyd's Syndicate, E6016.1 - Service of <br />Suit, E6017.2 - Nuclear Incident Exclusion Clause -Liability -Direct (Broad) Endorsement. E6018.2 <br />-Applicable Law Endorsement, and E6020.2 - War and Civil War Exclusion Endorsement <br />6. Optional Extension 12/24/36 months at 75/150/225 percent of the annual premium. <br />Period: <br />6. Notification of <br />claims to: <br />Hiscox Claims <br />520 Madison Avenue, 32nd floor <br />New York, NY 10022 <br />Fax: 212-922-9652 <br />Email: HiscoxClaims@Hiscox.com <br />POLICY FEE: <br />5% STATE TAX: <br />FSLSO FEE: <br />FHCF: <br />7. Policy Premium: $4.094 Administration Fee: N/A State Surcharge: N/A <br />quo <br />$2128.413 <br />Allied Healthcare Professional Liability Claims -Made and Reported Coverage Part: WCLAHC P0001 <br />CW (01/13) <br />Covered Professional Services: Solely in the performance of providing community health advocacy/education services. <br />THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES <br />LAW. PERSONS INSURED BY suRPL{$ LINES CARRIERS OO HOT HAVE THE <br />PROTECTION OF THE FLORIDA M$LFUJCE GWRANTY ACT TO THE EXTENT <br />OF ANY RIGHT OF RECOVERY FOR THE OeUGATIOH OF AIN INSOLVENT <br />UNLICENSED INSURER. <br />Requazi, S. 4a.bow- <br />Page 1 or 3 <br />