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CN'A <br />HEALTHCARE PROVIDERS <br />SERVICE ORGANIZATION <br />PURCHASING GROUP <br />CERTIFICATE OF INSURANCE <br />OCCURRENCE POLICY FORM <br />Print Date: 07 /2 9/08 <br />,4 _0200& -/%�7 <br />018098 970 H 0298755008 from: 12:01 AM Standard Time on: 08/01/08 <br />to: 12:01 AM Standard Time on: 08 /01/09 <br />Named Insured and Address. Program Administrator "",."' "'.n..:.< <br />Wesley A Bosch Healthcare Providers Service Organization <br />1000 E Santa Ana Blvd Ste 200 159 East County Line Road <br />Santa Ana, CA 92701 -3900 Hatboro, PA 19040 -1218 <br />Medical Specialty: Code: Insurance Provided b' . <br />Marriage /Family Counselor 80723 American Casualty Company of Reading, Pennsylvani <br />333 S. Wabash Avenue, Chicago, IL 60604 <br />OVERAGE PARTS LIMITS OF LIABILITY <br />$ 1,000,000 each claim $ 3,000,000 aggregate <br />........ _ .......... <br />included above <br />....... ...._ . . .... ........ ........... ... .. .. .. <br />included above <br />4i i U,000 per proceeain <br />4i....... 2.S, uu U_...._....._..._.._. .. ..........._._._._a9_g_regate.. <br />$ 10,000 <br />aggregate <br />$ 2,500 per deposition <br />t .......5 000 <br />aggregate <br />$ 10,000 ........ .. ......... .....per...incident <br />$... 25,000._.. ... _......_... <br />aggregate....... <br />... <br />21000 per person <br />100 000 <br />aggregate <br />$ 2,500 <br />aggregate .. <br />$ 500 per incident <br />$ 10,000 <br />aggregate <br />Coverage part C. Workplace Liability does not apply if Coverage part D. General Liability <br />is made part of this policy. <br />............. <br />included in A. PL limit shown above <br />..... <br />. _.._..._..... <br />ncluded in A. PL limit shown above subject to $150,000 sub -limit <br />$1,000,000._.... <br />aggregate._ .... <br />Coverage part D. General Liability does not apply if Coverage part C. Workplace Liability is made part of this policy. <br />.. <br />none <br />none <br />_._. ......... . <br />none <br />......... _ . <br />...... . . <br />none <br />none <br />..... ...... <br />none <br />.. . <br />Total Premium: $ 240.00 QUESTIONS? CALL: 1- 800 - 982 -9491 <br />iPolicy forms" and endorsei'nents atfached'af inception: <br />,sue <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 I3 <br />Master Policy # 188711433 <br />Keep this document in a safe place. It and proof of payment are evidence of your insurance coverage. <br />Chairman of the Board Secretary <br />G- 141241 -A (07/2001) Coverage Change Date: Endorsement Change Date: <br />