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ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY <br /> INSURANCE POLICY DECLARATIONS <br /> RENEWAL DECLARATIONS <br /> <br />ATTACH THIS RENEWAL DECLARATIONS TO YOUR EXPIRING POLICY <br /> <br />Policy Number: PHCP025487 <br /> <br />Philadelphia Indemnity Insurance Company <br /> <br /> Administered by: CPH & Associates <br /> 711 S. Dearborn, Ste. 205 <br /> Chicago, IL 60605 <br /> <br />Wesley A. Bosch <br />1000 E. Santa Ana Blvd. #200 <br />Santa Aha, CA 92701 <br /> <br />Affiliation: CAMFT <br />Professional Occupation: MARRIAGE&FAMILY <br /> <br />Coverage Term From: (Effective Date) 08/01/03 To: (Expiration Date) 08/01/04 <br /> at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above. <br /> <br />Retroactive Date (if applicable) <br /> <br />COVERAGE A - PROFESSIONAL LIABILITY COVERAGE LIMITS OF PREMIUM <br /> LIABILITY <br />Individual- Each Incident: $1,000,000 $320.00 <br />Aggregate: $3,000,000 <br />Association, Partnership or Corporation- Each Incident: N/A <br />Aggregate: N/A <br />COVERAGE B - SUPPLEMENTAL LIABILITY COVERAGE <br />Each Incident: I $1,000,000 <br />Aggregate: $3,000,000 <br />COVERAGE C - NON-OWNED AUTOMOBILE (optional) <br />Each Occurrence: <br />Aggregate: <br /> <br />Policy Forms and Endorsement: The expiring policy forms, endorsements and limits of insurance apply to <br />this renewal unless changes are shown on this Renewal Declaration. <br /> <br /> Premium (including taxes): $320.00 <br />Call the Administrator to Verify Claims History at 1-800-875-1911 <br /> <br />Authorized Signature <br />PHCP-01 (3/01) <br /> <br />ORISTINE LEE SHAW <br />Deputy City A~tomey <br /> <br /> <br />