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Sponsored by AVMA Veterinary Professional Liability <br />Insurance Policy <br />Certificate of Insurance <br />This policy provides occurrence coverage. Please review the policy carefully. ZURICH <br />ITEM 1: Insured by the stock company below and hereinafter called the U-VPL-l03-A-CW (07/07) <br />P L I T Company Zurich American Insurance Company <br />ITEM 2: Named Certificate Holder, member number, IRC, and address <br />Scott Henry Weldy, DVM <br />c/o Serrano Animal & Bird Hosp <br />21771 Lake Forest, Suite 111 <br />Lake Forest, CA 92630-2782 <br />Ii�l����l�itll�1t111111tt1t�ltlll��llltll�tl111�t�11t�llt�ll�l <br />Member Name Member No. IRC Class <br />WELDY SCOTT HENRY DR 24154 17 IV <br />ITEM 5: Premium and coverage summary <br />Liability $ 246.00 <br />TOTAL DUE: $ 246.00 <br />APPROVED AS TO FORM <br />Laura Stilt eedy <br />Assistant Cit Attorney <br />Master Policy Number: Certificate Number: <br />EOL 5241302-04 1 36548 <br />FOR INFORMATION OR TO FILE A CLAIM <br />PLEASE CALL (800) 228-7548 <br />ITEM 3: Policy Period From: 1/0 1 /2009 To: 1/0 1/2010 <br />12:01 am Standard time at the address of the Named Certificate Holder as <br />stated herein <br />ITEM 4: Limits of Liability <br />Each claim $ 1,000,000 <br />Aggregate $ 3,000,000 <br />ITEM 6: Forms Attached at Issuance: U.VPL-103-A Cw (07/07), U-VPL-loo-A Cw (onoa), U-VP1-- 09 -ACA (09 0a), <br />U-GU.319.E(05/96) <br />ITEM 7: Schedule of Plan Numbers and location(s) for <br />Veterinary Professional Bailee Extension Endorsement (if purchased): <br />For additional locations, please see the attached page <br />Location Number/Address <br />ITEM 8: Veterinary License Defense Coverage endorsement (if <br />purchased): Limit: $ <br />Authorized Signature <br />This payment coupon is not considered part of the policy. <br />10/07/2008 LMB 17 <br />Plan Number <br />This Certificate of Insurance is issued off the Master Policy held by the American Veterinary <br />Medical Association (A.V.M.A) Professional Liability Insurance Trust. By acceptance of this <br />policy the Named Certificate Holder agrees that the statements in the certificate and the <br />application and any attachments hereto are the Named Certificate Holder's agreements and <br />representations and that this policy embodies all agreements existing between the Named <br />Certificate holder & the Company or any of its representatives relating to this insurance. <br />Notice to the Company: Zurich North American -Specialties Claims <br />Attn: Professional Liability Claim Department <br />P.O. Box 307010, Jamaica, NY 11430-70 1 0 <br />Amount Enclosed/Charged: $I� 1�J �IF�! <br />Payment Options: 0 Check enclosed (Payable to the AVMA PLTT) ❑ Money Order 0 Visa 0 MasterCard <br />To pay by credit card, please complete the following: <br />TearAbove <br />DUE DATE: 1/01/2009 <br />Insured Signature Date: <br />Do not withhold payment pending <br />receipt of adjusted billing as this couh <br />cause cancellation of coverage. <br />AVMA PLIT Payment Address <br />P.O. Box 4389 <br />Carol Stream, IL 60197-4389 <br />www.avmaplit.coin <br />036548 090101 00024600 0013812000 3 <br />