ISO Form PR DS 01 12 97

Summary

COMPANY NAME AREA

PRODUCER NAME AREA

NAMED INSURED

MAILING ADDRESS

POLICY PERIOD:

FROM

TO

AT 12:01 A.M. TIME AT

YOUR MAILING ADDRESS SHOWN ABOVE.

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.

LIMITS OF INSURANCE

COVERAGE A

EACH MEDICAL INCIDENT LIMIT

INDIVIDUAL PROFESSIONAL LIABILITY AGGREGATE LIMIT (COVERAGE A)

COVERAGE B

EACH BUSINESS ENTITY INCIDENT LIMIT

PARTNERSHIP, LIMITED LIABILITY COMPANY, ASSOCIATION OR CORPORATION PROFESSIONAL LIABILITY AGGREGATE LIMIT (COVERAGE B)

RETROACTIVE DATE (PR 00 02 ONLY)

THIS INSURANCE DOES NOT APPLY TO INJURY ARISING OUT OF A "MEDICAL INCIDENT" OR "BUSINESS ENTITY INCIDENT" WHICH OCCURS BEFORE THE RETROACTIVE DATE, IF ANY, SHOWN BELOW.

RETROACTIVE DATE:

(ENTER DATE OR "NONE" IF NO RETROACTIVE DATE APPLIES)

DESCRIPTION OF BUSINESS

FORM OF BUSINESS:

( INDIVIDUAL

( PARTNERSHIP

( JOINT VENTURE

( LIMITED LIABILITY COMPANY

( ORGANIZATION, INCLUDING A CORPORATION (BUT NOT ...