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HEALTHCARE PROVIDERS SERVICE E PSQ <br />ORGANIZATION PURCHASING GROUP <br />r Digitally signed by.,L <br />A (feitif Late of 111q xia�ue Tori Piersor ,'Ief— <br />OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM Date: 2022.08.0211: 9;58 <br />-oy'00- <br />Print Date: 7/20/2022 <br />The application for the Policy and any and allsupplementary information, materials, and statements submitted therewith shall I <br />be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as I <br />if physically attached. I <br />PRODUCER BRANCH PREFIX POLICY NUMBER POLICY PERIOD <br />018098 970 HPG 0697816243 From: 12/10/21, to 12/10/22 at 12:01 AM Standard Time <br />Named Insured and Address: Program Administered bv: <br />Luis Martinez <br />301 W 2nd St Apt 241 <br />Santa Ana, CA 92701-5295 <br />Medical specialty: <br />Alcohol/Drug Counselor <br />Excludes Cosmetic Procedures <br />80723 <br />Healthcare Providers Service Organization <br />1100 Virginia Drive, Suite 250 <br />Fort Washington, PA 19034 <br />1-800-982-9491 <br />www.hpso.com <br />Insurance Provided by: <br />American Casualty Company of Reading, Pennsylvania <br />151 N. Franklin Street <br />Chicago, IL 60606 <br />Professional Liability $ 1,000,000 each claim $ 3,000,000 aggregate <br />Your professional liability limits shown above Include ththe following: <br />* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability <br />* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />$ 25,000 <br />per proceeding <br />$ 25,000 <br />aggregate <br />Defendant Expense Benefit <br />$ 1,000 <br />per day limit <br />$ 25,000 <br />aggregate <br />Deposition Representation <br />$ 10,000 <br />per deposition <br />$ 10,000 <br />aggregate <br />Assault <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments <br />$ 25.000 <br />per person <br />$ 1 D0,000 <br />aggregate <br />First Aid <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />Damage to Property of Others <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />Information Privacy (HIPAA) Fines and Penalties <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />Media Expense <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />General Liability <br />General Liability $1,000,000 each claim / $2,000,000 aggregate <br />Fire & Water Legal Liability Included In the GL limit shown above subject to $250,000 aggregate sublimit <br />Personal Liability $1,000,000 aggregate <br />Total $ 465.00 <br />Base Premium $465.00 <br />Premium reflects Self Employed , Part Time <br />Policy Forms and Endorsements (Please see attached list of policy forms and endorsements) <br />Chairman of the card Secretary <br />Keep this Certificate of Insurance In a safe place. It and proof of payment are your proof of coverage. There Is no coverage in <br />force unless the premium is paid in full. To activate your coverage, please remit premium in full by the effective date of this <br />Certificate of Insurance. <br />Coverage Change Date: Endorsement Date: 7/19/2022 Masi <br />r� i nawsvreo&tuvuweosv: _ <br />CNA93692 (11-2018) iS jF1 7764 ;Dlrndm <br />O Copyright CNA All Rights Reserved. _ rsuaxun a octane,: ode <br />