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<br />¡ f <br /> <br />. JUN-01-2004 19:27 <br /> <br />DONNA-DENNIS COLUCCI <br /> <br />Healthcare Providers Service <br />Organization Purchasing Group <br /> <br />949 770 8708 <br /> <br />P,01/01 <br /> <br />~NA <br /> <br />CNA PI,,:ta, <br />Chkago, It 6(1695 <br /> <br />Qterti fi'cate 0'£ ~ ltfiltr ttttr:e <br /> <br />IIHPSO <br /> <br />11~~'(~~~~~o...."'M""" <br /> <br />. Producer Brancb Prefix .: . Policv Nùß1bet' .. . . :,:J?åijcy'Periöø,' :.. <br /> froJD: 12:01 AM Standard Tiøe on: 05/03/04 <br />018098 970 HPG 273732971-8 to: 12:01 AM Standard Tiøe on: 05/03/05 <br />Named Insured and Address " .. .' ':,' PrdRrabl' Ädmiiiisttator' <br />. .. .' <br /> ¡J .- öÙ)03-lJ tv3 Healthcare Providers Service Organization <br />DENNIS A COLUCCI 159 East countô Line Road <br />23291 COBBLEFIELD Hatboro, PA 19 40-1218 <br />M¡SSIO~ VIEJO CA 92692-1674 <br />Medical Specialty: Code: : '~s1iranœ. J?ro=yjdèd þy <br />Alldiologist 80714 American Casualty Co. of Reading, PA <br /> CNA Plaza 26S Chicago, IL 60685 <br />COVERAGE PARTS ',::.:" . :: .'LiWr:S "QF LIABIl1tY <br /> : <br /> <br />A. PROFESSIONAL LlABIUTY <br />Professional Liabilit <br />Good Samaritan Liability <br />Personal Injury Liability <br />a p acement L1a i 1ty <br /> <br />$1 000 000.00 each claim <br />Included above <br />Included above <br />Inc u e a ove <br /> <br /> <br /> <br />000.00 <br /> <br />a <br /> <br />rate <br /> <br />B. Covera c Extensions <br />License Protection <br />Defendant ~en~e Benefit <br />Deposition Representation <br />Assa.ult <br />Medical Payntent$ <br />F1rst Aid <br /> <br />Dama e to Pro art of Others <br /> <br /> <br />$10,000.00 $25 000.00 a re ate <br />:', $10,000.00 ag regate <br />. ", <br />$2,500.00 per deposition $5,000.00 aggregate <br />$10,000.00 er incident $25 000.00 a :r-e ate <br />$2,000.00 per person $100,000.00 a r ate <br />,'. : $2,500.00 aggregate <br />. . <br /> er incident $10 000.00 a re ate <br /> <br /> <br />C. WORKPLACE LIABILITY <br />Workplace Liability <br />1re an Water Legal <br />Personal Liabilit <br /> <br />Liability <br /> <br />Coverage part C. does not a Iy if Covera e art D. is made part of this policy. <br />Included in A. Professional Liability Limit shown above <br />Included,above subject to $150,000 sub-limit <br /> <br />. .,:: $1 000,000.00 a re ate <br /> <br />. "'. <br /> <br />Hired Auto & Non Owned Auto <br />F~re & Water Lega L~a ~ ~ty <br />Personal Liability' <br /> <br />None <br />None <br /> <br /> <br />art C. is made part of this policy. <br />None <br /> <br />D. GENERAL LIABILITY <br /> <br />Covera e part D. does not a <br /> <br />~vor]::plac'~ Liabilit~l <br /> <br />,'" <br />, . <br /> <br />C-144S72-A C-145184-A C-121500C <br />G-147292-A <br /> <br /> <br />'," <br /> <br />None <br />None <br /> <br />Total Premium $129.00 <br />. Policy forms and endorsements attached /it' ~'. <br /> <br />QVESTION~? CALL: 1-800-982-9491 <br /> <br />G-123846D-04 G-121503C <br /> <br />He;I\UJ<are Pr<McJel!¡ ~IC. OI'$a.o,.illÍOII ÍII a diYialw\ ot AffiWty InBUtIItICi SeMt.-u, W.; ill NY oIIId NH. At:! AffiniIy IIl3IWllce A;ißq: in MN and OK, AlS Atfinity lnsurmt<:i <br />A&ißC)l. Inc.: 81d ÙI CA, AI:! AftiNty hU\JN/1G4I Agcrwy. Inc. "b. Aon DirOÇ\ Imtnncc Atlministretcms J..ic0l\$ll! ¡¡O79~5. <br /> <br />$129.00 PREMIUM <br /> <br />$0.00 CIGA SURCHARGE <br /> <br />Master Policy: 1887H433 <br /> <br />MJ~n( <br /> <br />Chairman of the Board <br /> <br />~~~~ <br /> <br />Keep this document in a safe place. Trus and <br />your cancelled check act as proof of coverage. <br /> <br />Secretary <br /> <br />602 X)( <br /> <br />0OOOOO8-N O~OS24 NENHCP 8/01 H19~RH 04145 <br /> <br />TOTAL P.01 <br />