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<br />Veterinary Professional Liability <br />Insurance Policy <br />Amended Certificate of Insurance <br />PLEAS¡¡ Al1"ACH TO YOUR '('UCY. <br /> <br />13129225358 P.Ð4/Ø5 <br /> <br />9 <br />ZURICH <br /> <br />DEC-23-2ÐÐ1 <br /> <br />15:25 <br /> <br />Sponliured by <br /> <br />AVMA <br /> <br />II <br /> <br />P LIT <br /> <br />ITEM I: Inlarod by doc otock """P'.Y below a.d llerolnafter""'d tho C...pmy ^.U.vPL.'03.A-ÇW(071114) <br />Zurich A...rica. lua..... C...pa.,. <br /> <br />ITiM 1: Nom'" Certificate Halder, ....,ber ._ber, iRC, and add"" <br /> <br />Lorrie B. Boldrick DVM <br />1330 North Glassell Street <br />SuileM <br />Orange, CA 92867 <br />1,1.",1.11,,1,,11,,1.,,11,,1.1 <br /> <br />Maslcr Policy Number: <br />BOL 5241302.00 <br /> <br />Cc1Iificate NUII1ber: <br />07309 <br /> <br />FOR lNFORMA TION OR TO FILE A CLAIM <br />PLEASE CALL (800) 218-7548 <br /> <br />n1M3: Changosmadeetrcelive: 1/0112005 <br />12:01 1m Standard 1ime aUM 4dchI. oIlhc N....d C.nifiÇ¡lw HoIdor.. <br />Ibkd beNilt. <br /> <br />Member Name <br />BOLDRlCK LORRIE DR <br /> <br />Member No. <br />21185 <br /> <br />~ <br />16 <br /> <br />em <br />III <br /> <br />ITEM 4: Limits of Liability <br />Each claim <br />Aggregate <br /> <br />$1,000,000 <br />$ 3,000,000 <br /> <br />lTEM 5; fu"l!1ium ond cover..., s..mmllry <br /> <br />ITItM~: ['ann. Attached ILr..wonc:o:: U-VPL-I03.A c.'W (07/04). U-VPL-IOO-A CW (07104) <br /> <br />Lial>llity <br />ADDITIONAL <br />PREMmM DUE: <br /> <br />$ <br />$ <br /> <br />ITEM 7: S<hodule of PI.. Numbers ond 1ooution(s)f.. <br />Veterinary ProI_IIJaiI.. Extension EncIo_t (irplll""""): <br />For oddiûoruoIl"""Iion.. pi.... see the atùU:hed pail" <br /> <br />l.ocation NumbctfAdd~5 <br /> <br />P1¡¡n Number <br /> <br />ITEM': Veterinary Ucense DefCIIIC C""""'IC CDlorscnIOIII (ir <br />purcooliCd); Limil; S <br /> <br />.o\utborixcd Sipiwro <br />,]:,,,l' <br />p~r ,.,..~. <br /> <br />'J1riJ CatiflQlt ofln-.nco ¡" iuucd o«ttu: ...... Policy hold by dw AlMriCiln v~ <br />f*dioal AllIOC:Ì8IÎoD ("- V.M.A) ProlclllilJMl Lillbility In.,,.,,:. Tnm. By IþCOOplarK:lI oflhii <br />puIIe;y &he N....... Ol1lfInÞ RaWtr -gees that 1bc atatcnxDb ÚI the t:atifKiM - dw <br />app&i&:8Iion and lilY ilU",hnwnb her.o.~ Ihø Namell r.ardftnte "aNn'. .....:ct1h1rf.a and <br />rtpmen8lÛM and dta.lhi, IN)1icy onnbadiaa anasrccm18t. cmbn' between lhe N"" <br />eerfilk8lco IIoIder" lhc C-1tM3' or Illy UfÍ'l5 rcprc:a¡IIIt!ltives rtI.11in& 1o tbi... iftllunnçc. <br /> <br />N«jCC! to tM CCllJlpMY: <br /> <br />ZuriÐh Nðdh American4pcdabiel CIIIinu. <br />/\Un: rror.øiønal Li:lbility CI~m J>cpartmanl. <br />P.O. 801(301010. hmaic:a. NY 114.10.1010 <br /> <br />P~l'~ <br /> <br />Do... wtc~lIoId " 'III"" """".~ '\\"'Ij> <br />....,.". of ad""", IIIIIIIIr ...... ...101 <br />r-.~eU"'" armnn... <br /> <br />1/0112005 <br /> <br />¡ 2123/2004 <br /> <br />KDS <br /> <br />16 <br /> <br />Amo.., ëncJoooðIt:luw¡¡ed: $ <br /> <br />DIIE DAtt: <br /> <br />Pay,uoo, Option., 0 Check anc1o"'¡ <br />To plY hy ~cdit card,. plca8C complete the followiag: <br /> <br />0 MOIII.'Y Ordo.,. <br /> <br />U Visa <br /> <br />0 MalwrCord <br /> <br />.~¡~ï_l <br /> <br />A VMA PUT Payment Addres. <br />P.O. Box 4389 <br />Carol SUeom,1L 60197-43K') <br />~'@'m\!!p.!it- <br /> <br />. "Please indicate the pelÇCDtagc of your individual professional activity related to: <br />Equine Food anilllal Small animal ~IOO% <br /> <br />InllUl'o:.d Sisnaturc <br /> <br />--------- <br /> <br />~~-,........-...~.........-,--......._--- <br /> <br />00130' 050~D1 00000000 DDD1'33DDD 3 <br /> <br />P3 <br />