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<br />~d/ld/~~~~ 1~:34 <br /> <br />~4~-~jI1LjL4 <br /> <br />DENNIS COLUCCI MA <br /> <br />PAGE 04 <br /> <br />" <br /> <br />" <br /> <br />~NA <br /> <br />HEAL THCARE PROVIDERS <br />SERVICE ORGANIZATION <br />PURCHASING GROUP <br />CERTIFICATE OF INSURANCE <br />OCCURRENCE POLICY FORM <br /> <br />Print Dale: 05/16/08 <br /> <br />IV, D2()Ob- // b <br /> <br /> <br />Dennis A Colucci <br />23961 Calle De La <br />Laguna HillS, CA <br /> <br />Medical SpeCialty: <br />AudiologIst <br /> <br />Magdalena St <br />92653-3679 <br />Code: 80716 <br /> <br />A. PROFESSIONAL LIABILITY <br /> <br />" <br />..__._--_._-_..._.._._...._._--~.. --_._--~---- <br />profeSSio. nal Liability (PL) '.. $ 1,000,000 each claim <br />'-GOod Samaritan UiillilffY--"- ..-..-- includ-ed 'a60Ve-~--' <br />persorialTnjiiry-[lability ..-- ------includedabove-. <br />rJlaIpllieememIlaOlilty-------. --Included above':: <br />-----...._~_.__.,"___ ~___......____.._,i...._ <br /> <br />$"s,oOO,OOO -"aggre!gate-" <br /> <br /> <br />B. COVERAGE EXTENSIONS: <br />license Protection <br />Defendant ExpenseBenefit <br />DeP~~uon ~epresent!l.!~o.!'''::._ . <br />Assault <br />- MedTCarr>a~m~.lI.ts-:...__..:__......_ <br />First Aid ...___ . <br />.._ Da~a~_~~.!"~oper:t.Y. of O~~':"~.._.___.____.__.____.._. pe~~cict:,!lt <br /> <br /> <br />"'25':000 --aiig regate .. <br />10,000 aggregate <br />5,000 aggregete <br />-25;OOO----.~......ii{lgregate -. <br />100 000 .._:.~:=:__aggi-'eQal~::::: <br />2 500 ._.___.1!gg[~.t.e..__ <br />_~9flOO _____._~ggregat~_ <br /> <br />C. WORKPLACE LIABILITY <br /> <br />Coverage part C, WOfkpt;;.Oe: L.IQblllt)' ~ not IilIpp~ if C~e part D. Genel'8111ablllty la made part of tills policy. <br /> <br />~ WorkPlaceuabiiiti.--..~_."-.=... included in},. F:q~ shoWn above "-. .. .=--===.:::-.:::::: <br />._ Fire ..!..vv~!g,~egaT[la6!1!!>'...._ included in A. PC"[lmit shown abOVE! sub'ect t~J150,000..~ub-1iffi'1l ____._ <br />_..!"ers~na, ~~aDilitr.... _. ",1,000,000 . . aggregate <br /> <br />D. GENERAL UABILITY <br /> <br />Covereg9 part D. General Liability does not~ly If CoY$rage part C. Workpiece Usblllty IE!; made pan cf thIs policy. <br /> <br />o;;.-.r"."",,(.c;--~.~ <br />Hired Aufii'&l\J'Oriowneo Aulo---:=:-: ......I:l~~ ======_ ~ <br />J:~~~!~~~~==~=_ . none ~~..-===.==:======~~~=::.: <br />I Total Premium: $ <br /> <br /> <br />G-121500-C G-121503-C G-121501-C1 G~145184-A <br />G-147292-A G-144872-A G-123846-D04 <br /> <br />" ,~ ~}d <br /> <br />~~ <br /> <br />," <br /> <br />Master Policy # 188711433 <br />1("1' this document In <".l $af'E1 place. It and proof-of paymenl a~ evider'lce of your Insurance coverage. <br /> <br />~./B::;- rl-( ~r~JIv ~ <br /> <br />G.141241-A (07/2001) <br /> <br />Coverage Change Date: <br /> <br />Endorsement Change Date: <br />