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463 <br />HISCOX <br />Effective with UNDERWRITERS AT LLOYD'S, LONDON <br />Administered by Hiscox Inc. <br />520 Madison Avenue 32nd Floor, New York, NY 10022 <br />(646) 452-2353 <br />Insurance for Allied Healthcare Professionals <br />DECLARATIONS <br />THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES 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 UNLICENSED 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.: MEO1505401.14 7270 NW 12th St Ste 700 a01""emu GABQ+ <br />Renewal of: NEWMOM Nn�T <br />Miami, FL 33126-1929 USed AGOG' A1291847 <br />PRODGGGI6 AGENT: <br />1. Named Insured: Indian River Healthy Start Coalition Inc & Healthy Families of Indian River JACKE SAVELL <br />87 Address: 333 17th St Ste 2R V O BEACyAL H. FLPOINTE <br />VERO BEACH, FL 32980 <br />Vero Beach, FL 32960-7100 <br />2. Policy Period: 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 Tune) at the address of the Named Insured. <br />3. General terms and <br />conditions wording: <br />WCL P0001 CW (05/13) <br />The General terms and conditionsapply 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 Exdusion Clause -Liability -Direct (Broad) Endorsement, E6018.2 <br />- Applicable Law Endorsement, and E6020.2 - War and Civil War Exclusion Endorsement <br />5. Optional Extension 12/24/36 months at 75/150/225 percent of the annual preinium. <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: HiscoxCiaims@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 />MUG <br />am <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 />THS INSURANCE IS ISSUED PURSUANT To THE A.ORIOA StRPL.U9 LINES <br />LAW. PERSONS IIID BY SURPLUS UNES CARRIERS 00 NOT HAVE THE <br />PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT <br />OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF ANY INSOLVENT <br />UNLICENSED INSURER. <br />Ro+1a.4.4 S. Gabor <br />PLige 1 of 3 <br />