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<br />. <br /> <br />./ Healthcare Providers Service <br />~NA Organization Purchasing Group LtHPSO <br /> Olertificate of ~nsurance <br />CNA Plaza, HoolIla....',.,wIonSOrvl<ao.p....- <br />Chicago, IL 60685 <br /> OCCURRENCE POLICY FORM <br />Producer Branch Prefix Policy Number Policy Period <br /> from: 12:01 AM Standard Time on: 05/03/05 <br />018098 970 HPG 273732971-8 "~. 1?n1'M "'im~ ~n. n.,nom.. <br />Named Insured and Address Pro~ram Administrator <br /> Healthcare Providers Service Organization <br />DENNIS A COLUCCI 159 East countg Line Road <br />23291 COBBLEfIELD Hatboro, PA 19 40-1218 <br />MISSION VI~JO CA 92692-1674 Insutance Prllyided by <br />Medical Specia ty: 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 />A. J.'KUtoc~~IUN!\L LL'ffiILrr-r--~.~.~n_-. <br /> ., a.. ~, nnn nnn nn ~'rh rhim .c nM Mn un <br />Good Samaritan Liabi1itu Included abo"e <br />Personal Iniuru Liabilitu Included above <br />Ma1e1acement Liability Included above <br />B. Coverage Extensions <br />,.. n~ __ SI0.00000 n~~ lin~ o?< nnn un <br />Defendant ~Ynense Benefit 010 000.00 aaareaate <br />Denosition Renresentation $2,500.00 ner denosition S5 000.00 aaareaate <br />., S10 000 nn n~'" i__i"__" 0". nun un <br />Medical Pauments $2 OOO.OOnernerson s100000 00 an"renate <br />first Aid ~2 500.00 aaareaate <br /> >n nF S<nn no n~~ i, . . ~'o nnn nn <br />C. WORKPLACE LIABILITY Coverage part C. does not aooly if Coverage oart D. is made Dart of this ooliev. <br />Workolace Liabilitu Included in A. Professional Liabilitu Limit shown above <br />fire and Water Leaal Liabilitv Included above subiect to $150,000 sub-limit <br /> . . .~.".'.. I ., unn nnn nn <br />D. GENERAL LIABILITY Covera e Dart D. does not applv if Coverage Dart C. is made nart of this policy. <br />- .-_. -. N"""- --'- --+- - -~. - .- "" .- --- ....--- . <br />Hired Auto & Non Owned Auto None <br />fire & Water Leaal Liabilitv None None <br /> '.i....i1,... .., <br />Total Premium $129.00 <br />Policy 'forms and endorsements attached at incention QUESTIONS? CALL: 1-800-982-9491 <br />G-144872-A G-145184-A G-121500C G-121501C G-l23846D-04 4hi)~Sb <br />G-147292-A _.&?~ 'f(') FORM <br /> \ ,,~~,. <br />HeaIlhc1n Providem Servic. OJpJitalion ill a diviaion of Affinity IJUjI)tlllll:a Sarvicell. ln~.: in NY Ill4 NH. AlS AfIinily lIlsuranI;c ,,&enCy; in MN:md OK. ~ ~ Wul'anI;e 7 <br />Ag,tncy, inc.; II1d in CA. AlS Affinity btautance Agency. Inc. dba AM Direct Inruranco ~ LiceDM IW079S46S. . __H'~ ___ - <br /> , . ~lIrll ~!ill Sheedy' <br />$129.00 PREMIUM $0.00 CIGA SURCHARGE Master lil\Jiji3!lll~1O\1j1~6rnev <br />~nJ:::l!i ~kztlJ~ 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 RENBCP 1/05 R136HK 05055 <br />