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CNA <br />HEALTHCARE PROVIDERS <br />SERVICE ORGANIZATION <br />PURCHASING GROUP <br />CERTIFICATE OF INSURANCE <br />OCCURRENCE POLICY FORM <br />Print Date: 0 6/2 8/07 <br />A. PROFESSIONAL LIABILITY <br />018098 <br />970 <br />HPG <br />0298755008 <br />from: 12:01 AM Standard Time on: 08 /01/07 <br />to: 12:01 AM Standard Time on: 08 /01/08 <br />amedlnsured artd 4dtlress x <br />Pr..og,rarrAdrTtntstratorz <br />Wesley A Bosch <br />1000 E Santa Ana Blvd Ste 200 <br />Santa Ana, CA 92701 -3900 <br />Medical Specialty: Code: <br />Marriage /Family Counselor 80723 <br />Healthcare Providers Service Organization <br />159 East County Line Road <br />Hatboro, PA 19040 -1218 <br />Insurance,Prov,ided b °:. <br />American Casualty Co. of Reading, PA <br />CNA Plaza 26S Chicago, IL 60685 <br />OVERAGExPARTS "'' LIMITS „QF LIABILITY: ", <br />A. PROFESSIONAL LIABILITY <br />Professional Liability (PL) <br />$ 1,000,000 each claim <br />$ 3,000,000 <br />aggregate <br />Good Samaritan Liability <br />included above <br />Personal Injury Liability <br />... ......... . - _......_ <br />included above <br />: <br />._ <br />Matplacement Liability <br />_ ......_ <br />included above <br />B. COVERAGE EXTENSIONS: <br />_...._ —._ <br />License Protection <br />..... - . ....... _. . <br />_.. ... ......_...._............_.. <br />1 ,000 per proceeding <br />. <br />$ 25 000 <br />- .._......_.. <br />aggregate <br />Defendant Expense Benefit <br />! <br />$ 10,000 <br />aggregate <br />..... ... ... <br />Deposition Representation <br />.. . ...... ......._ <br />$ 2,500 per deposition <br />_ <br />$ 5,000 <br />aggregate <br />Assault <br />$ 1..0,000 per incident....$ <br />25,000..._ <br />aggregate....... <br />Medical Payments <br />$ 2 000 er erson <br />$ 100L000 <br />aggregate <br />... <br />First d._.... - -.. <br />$ 2,5_00 <br />a9g.regate <br />Damage to Property of Others <br />$ 500 per incident <br />$ 10,000 <br />aggregate <br />C. WORKPLACE LIABILITY <br />Coverage part C. Workplace Liability does not apply if Coverage part D. General Liability <br />is made part of this policy. <br />_.... _ y....... <br />Workplace Liability <br />_....__._....__...._... <br />included in A. PL limit shown above <br />_...... .. _ <br />...._.......__.._....._-....... <br />Fire &Water Legal Liability <br />........................ ............. ... <br />---- ................_................. ....... ... _... .... _.:........................... .......... ......-_-.........._......_...._.._....._..__....... ........... ......-----_......__.. ..__..._... .......... _........_ ................... <br />lincluded in A. PL limit shown above subject to $150,000 sub -limit <br />Personal Liability <br />$1,000,000 <br />aggregate <br />D. GENERAL LIABILITY <br />Coverage part D. General Liability does not apply if Coverage part C. Workplace Liability <br />is made part of this policy. <br />._ . :. .... ..... —__ ................. <br />General Liability (GL) <br />......... . ............. ............... _ ..... _ . ..... .......... ....... ..... ....... ... ...... <br />none <br />... _ ....... _ ........ ............. ....... ....... - <br />none <br />... -- ....... <br />HIred-A_ uto &Non 0 "caned Auto <br />__. . <br />Fire & Water Legal Liability <br />none <br />none <br />Personal Liability <br />_ <br />none <br />Total Premium: $ 240.00 QUESTIONS? CALL: 1- 800 - 982 -9491 <br />Policy forms and"°e ndorsements ,�attached,'at;ince'0tion ,, <br />n -" <br />G- 121500 -C G- 121503 -C G- 121501 -C1 G- 145184 -A <br />G- 147292 -A G- 144872 -A G- 123846 -D04 G- 123828 -B lt% �A_ <br />Chairman of the Board <br />Master Policy # 188711433 <br />this document in a safe place. It and proof of Davment are evidence of vour insurance rnverane <br />Secretary <br />G-141241 -A (07/2001) Coverage Change Date: Endorsement Change Date: <br />