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<br />/. Healthcare Providers Service <br />'~NA Organization Purchasing Group IIHPSO <br /> <!I.ertifi:cat.e of ~n5uran.c.e <br />CNA Plaz"", HaJtb,... 1"0.;.1", S.",i<oO<QaJ~,..i""'- <br />Chicago, IL 60685 <br /> OCCURRENCE POLICY FORM <br />Producer Branch Prefix Policv Number Policy Period <br /> from: 12:01 AM Standard Time on: 05/03/05 <br />018098 970 HPG 273732971-8 tn. '? n, 'M "~on"ow' '1"mA nn. n<'--'..- <br />Named Insured and Address Program Administrator <br /> N -~ d 003 ~()03 Healthcare Providers Service Organization <br />DENNIS A COLUCCI 159 East counto Line Road <br />23291 COBBLEE'IELD Hatboro, PA 19 40-1218 <br />MISSION VIEJO CA 92692-1674 Insurance Provided by <br />Medical Specialty: Code: <br />Audiologist 80714 American Casualty Co. of Reading, PA <br /> CNA Plaza 26S Chicago, IL 60685 <br />COVERAGE PARTS -- LIMITS OF LIABILITY <br /> -------- -------- --..-- .-- .-- -~-'- ,------- <br />~l'KUt tSSIONALLIABILITY-'-- - <br /> ;nn~' T.i~t;' ;~" ~, nnn nnn _ nn ..~,.,h nlo'm ,,,'- nnn nnn no <br /> Good Samaritan Liabi1itv Included above <br /> Personal Iniurv Liabilitv Included above <br /> Ma1p1acement Liability Included above <br />B. Coverage Extensions <br /> T< n. '.inn "" n non nn nA~ n~n, ..., .- ~?, nnn nn <br /> Defendant Expense Benefit s10 000.00 aaarenate <br /> Deposition Representation $2 500.00 per deposition $5,000.00 aaareaate <br /> . ,,. ~, n nnn nn n"~ in,.... -'- ~ ~?, nnn nn <br /> Medical Pavments s2 000.00 ner nerson sioo 000.00 aaarenate <br /> First Aid $2.500.00 aaarenate <br /> tn nf" nt""~" ~'nn nn n"~ in,....-'- ~ ~'n nnn nn <br />C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. <br /> Workplace Liabi1itv Included in A. Professional Liabilitv Limit shown above <br /> Fire and Water Legal Liability Included above subject to $150,000 sub-limit <br /> Personal Liabi1itv ~1 ana 000.00 <br />D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. <br />-,----- -WOr]{nTa-C"Lrall1.ln:'r - -- - -'-'- ---~- - - Non-"-' -..- -t-u !fone -- _._m <br /> Hired Auto & Non Owned Auto None <br /> Fire & Water Legal Liability None None <br /> Personal Liabilitv "nnA <br />Total Premium $129.00 <br />Policy forms and endorsements attached at inception OUESTIONS? CALL: 1-800-982-9491 <br />G-144872-A G-145184-A G-121500C G-121501C G-123846D-04 ,-~503C <br />G-147292-A 4 P VcE!) AS, TO FORM <br /> ~Q-~ <br />Heallhcare Providers Service Organization is a division of Affutity Im1P1lllce Services, Inc.; in NY and NH, AIS Affinity Insurance Agency; in MN and OK: _ -~ s. Affinity Ins~ce <br />Agency, Inc.; and in CA, AIS Affinity Insurance Ageney, Inc. dbaAon Direct Insw"Wlce Administrators License #0795465. ". --, - . ..- . f ___... <br /> ~!tHiiI ~,itt Shliedy <br />$129.00 PREMIUM $0.00 CIGA SURCHARGE Master !.\JhPlffi.8Ip\ljl4\li\,;rn., <br />~n/:::l!i ~~[A;h Keep this document in a safe place. This and <br /> your cancelled check act as proof of coverage. <br /> Secretary <br /> <br />604 XX 0000088-R 050224 RENHCP 1/05 R136HM 05055 <br />