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Medical payments MEDPM <br />5,000 <br />01750 01750 <br />U.S. longshore & harbor WC act USLH <br />ADDITIONAL COVERAGES <br />Ref #Description Edition DateForm No.Coverage Code <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Ref #Description Coverage Code Form No.Edition Date <br />Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium <br />Copyright 2001, AMS Services, Inc.OFADTLCV <br />DocuSign Envelope ID: A5FFE04F-8470-4F98-AA51-99352A4A6BA6