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<br />"--, .. <br />1 ---. <br /> <br />CNA <br /> <br />HEAL THCARE PROVIDERS <br />SERVICE ORGANIZATION <br />PURCHASING GROUP <br />CERTIFICATE OF INSURANCE <br />OCCURRENCE POLICY FORM <br /> <br />Print Date: 07/29/08 <br /> <br /> <br />~~ER~J;iM__ _ <br /> <br />A. PROFESSIONAL LIABILITY <br /> <br /> <br />Professional Liability (PL) 1,000,000 each claim <br />--Giioa-samaiffaiiTfablHfy-------includedabove------------------- <br />-l5ersoiiallii]uryUabHity----------TilciliCiildabove---------- <br />_lin~rpl~~~JTj~llj:~f~~ilijf::::::_=:::::::f~~i~~~-a:~9~E:::::::::_::::::::::::== <br /> <br />C. WORKPLACE LIABILITY <br /> <br />Coverage part C. Workplace Liability does not apply if Coverage part D. General Liability is made part of this policy. <br /> <br />....----.-..--.-.-......--.-..-"..--.-.-.-.-.--...-.--....-----........-..-.-.-...-.-------.--...---.---.--.-.-..--.-.-.-.........-.--.-.--...-..----...-.-.--.-.--------..--.--....-..---.-.----.--... <br />..-.-.----.---.-.-...-..-----.-.--.-....-.-.----....-....-.-.--.-.--.-....-.----- <br /> <br />Workplace Liability included In A. PL limit shown above <br />---F-lre&Wafer Leija-i-L1ilblHiy--- --- fnauifedTri-A~P[limiCstiownaIiovesliiifecfto$I50:000su-b--nmil----- --- ---- <br />.. ~ ~ ~_~!.~_?~~~_~~.~.~~:~~.~.(!!X_~__._____ ... _.._____._.._...__...._._ i[:lii:lili~i!!~ll:j!l[iiil::ii~:~~~i~ili~!il~i!i!!nmiliiil!~~ni!i~ilii!!!I!mU!iiii~~lli~il!liii~:!i~il~~ <br /> :.:.:.~~~~=~_~~;_~_~~~~.~_~.:.~~~_~-_~=:.::~.~~~~~~~~~~.~.~.:: <br /> <br />D. GENERAL LIABILITY <br /> <br />Coverage part D. General Liability does not apply if Coverage part C. Workplace Liability is made part of this policy. <br /> <br />General Liability (GL) none <br />.---.--Hifs'fA"lJt'o.-.lfNon-c:fwns(fAuto-.-- -....-.-.- - '-..-.-.......-none.-....-.--~---.-.-.-.-.....".--..--.--.-.-.-...-.-~-.-..-.-....-.-.--- <br />Firei!;"Wilter[egilTliabiTiiy-------nons'------------------------ <br />-, -p_~~~o:~~j:~[~~iTi~:=:::::::::::: <br /> <br />Total Premium: $ <br />:llt1!llCI1[tlt!fi$;"Jl'i:f~I!l, <br />G-121500-C <br />G-147292-A <br /> <br />---.---.-- ._.-.....-~........_._._-----_..._......_-,,-.._...._..._._-._.--.--.-.-..-...---.--.-...-.-.-.-"...-.-.--.-.. .-.----..-.-.-.. .-.-....------.-..---.--..-.---.-.-.-..------.-.-.........-. <br />".-..-......-.-.-..- <br /> <br /> <br />240.00 <br />i!~ilm!li!t!l~!$t!Ilfj]~1 _~: <br />G-121503-C G-121501-Cl G-145184-A I <br />G-144872 -A G-123846 -D04 G-123828-B, 0,1) <br /> <br />f(J , <br /> <br />Master Policy # 188711433 <br />It and proof of payment are evidence of your insurance coverage. <br /> <br />Keep this document in a safe place. <br /> <br />M J~ f1/ <br /> <br />Chairman oftha Board <br /> <br />~r~JIv~ <br /> <br />G-141241-A (07/2001) <br /> <br />Coverage Change Date: <br /> <br />Endorsement Change Date: <br />