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POLICY FORMS & ENDORSEMENTS <br />The following are the policy forms and endorsements that apply to your current professional liability policy. <br />COMMON POLICY FORMS & ENDORSEMENTS <br />FORM # <br />G-121500-D (04-08) <br />G-121501-C1(07-01) <br />CNA94164 (11-18) <br />G-145184-A (06.03) <br />G-147292-A (03-04) <br />GSL15563 (02-10) <br />GSL15564 (10-09) <br />GSL15565 (03-10) <br />GSL17101 (02-10) <br />GSL13424 (05-09) <br />CNA80051 (09-14) <br />CNA80052 (10-14) <br />G-123846-D04(07-01) <br />CNA81753 (03-15) <br />CNA81758 (01-21) <br />CNA82011 (04-15) <br />CNA89027 (10.17) <br />CNA79575 (07-14) <br />CNA89026 (05-17) <br />G-121504-C (07-01) <br />G-123828-B (07-01) <br />G-141231-A (07-01) <br />FORM NAME <br />Common Policy Conditions <br />Occurrence Policy Form - California <br />Amendment Definition of Claim Endorsement <br />Policyholder Notice - OFAC Compliance Notice <br />Policyholder Notice - Silica, Mold & Asbestos Disclosure <br />Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs <br />Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion <br />Healthcare Providers Professional Liability Assault Coverage <br />Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br />Services to Animals <br />Amended Definition of Personal Injury Endorsement <br />Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />California Cancellation and Non -Renewal <br />Coverage & Cap on Losses from Certified Acts Terrorism <br />Notice - Offer of Terrorism Coverage & Disclosure of Premium <br />Related Claims Endorsement <br />Entity Exclusion Endorsement <br />Exclusion of Cosmetic Procedures <br />)Additional Insured General Liability <br />Media Expense Coverage <br />General Liability Form <br />Certificate Holder <br />Additional Insured Healthcare Entity <br />PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC <br />TO YOUR STATE AND YOUR POLICY PERIOD. <br />For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance <br />Guaranty Association. <br />For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement <br />Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. <br />As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been <br />applied to your insurance premium and is separately itemized on the Declarations page or billing <br />instrument attached to your policy, as required KRS. §136.392, <br />For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. <br />For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association <br />- 2012 Regular Assessment. <br />Form #:CNA93692 (11-2018) <br />Master Policy #: 188711433 <br />Named Insured: Luis Martinez <br />Policy #: 0697816243 <br />0 Copyright CNA All Rights Reserved. <br />e Wpk Mv��kDMdw� <br />(iEV IflVED b APPRd.� 9Y: <br />aax Marwgenm� nm�,i aa� <br />