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<br />Proposal of Insurance For Naveed Haider, M.D. <br />Page 15 of 16 <br /> <br />Client Authorization to Bind Coverage <br />After careful consideration of Gallagher’s proposal dated October 25, 2016, we accept the following coverage(s). Please check the <br />desired coverage(s): <br /> <br /> <br /> <br />Premiums for the authorized policies above are due and payable as billed, in full or as insurance company installments. Premiums may be <br />financed, subject to acceptance by an approved finance company. Note: Following acceptance, completion (and signature) of a premium <br />finance agreement with the specified down payment, is required. <br /> <br />PROVIDE QUOTATIONS OR ADDITIONAL INFORMATION ON THE FOLLOWING COVERAGE CONSIDERATIONS <br /> <br /> <br /> <br /> <br /> <br />It is understood this proposal provides only a summary of the details; the policies will contain the actual coverages. <br />We confirm the values, schedules, and other data contained in the proposal are from our records and acknowledge it is our responsibility <br />to see that they are maintained accurately. <br /> <br />Limitation of Liability. We agree that your liability to us arising from your negligent acts or omissions, whether related to the insurance or <br />surety placed pursuant to these binding instructions or not, shall not exceed $20 million, in the aggregate. Further, without limiting the <br />foregoing, we agree that in the event you breach your obligations, you shall only be liable for actual damages we incur and that you shall <br />not be liable for any indirect, consequential or punitive damages. <br /> <br /> <br />Agent Signature Client Signature <br />October 25, 2016 <br /> <br />Dated Dated <br /> <br />Bind Coverage Line of Coverage Carrier Est. Cost <br />[ ] Accept [ ] Reject Medical Malpractice Kinsale Insurance Company $5,443.63