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S; , Liberty_ <br /> fj lnternati <br /> underwriters. <br /> Healthcare Professional Liability <br /> LIBERTY INSURANCE UNDERWRITERS INC. <br /> (A Stock Insurance Company,hereinafter the"Company") <br /> ENDORSEMENT NO. <br /> Effective Date: 07/01/2019 <br /> Policy Number: AHY-630201008 <br /> Issued To: Lynn D Shatz <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> ADDITIONAL INSURED ENDORSEMENT <br /> This endorsement applies to: <br /> Professional Liability Coverage Part Only 0$ Additional Premium <br /> General Liability Coverage Part Only 0$ Additional Premium <br /> Professional Liability and General Liability Coverage Parts ❑$ Additional Premium <br /> In consideration of the premium charged, any Designated Entity shown below shall be included as an <br /> additional Insured,but only as respects claims arising out of the sole negligence of the individual or entity specified in <br /> the PERSONS INSURED Section of the policy. <br /> Designated Entity Schedule <br /> City of Everett 3025 Lombard Avenue <br /> Officers.Agents and Employees-(GL Coverage Only) Everett WA 98201 <br /> Cascade Job Corps NAME 1950 Northern State RDRESS <br /> (GL Coverage Only) Sedro Woolley WA 98284 <br /> NAME ADDRESS <br /> NAME ADDRESS <br /> NAME ADDRESS <br /> ALL OTHER PERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. <br /> 1 1 <br /> HCPL-8003 (Ed.01/14) <br />