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POLICY FORMS & ENDORSEMENTS <br /> The following are the policy forms and endorsements that apply to your current professional liability policy. <br /> COMMON POLICY FORMS & ENDORSEMENTS <br /> FORM # FORM NAME <br /> G-121500-D (04-08) Common Policy Conditions <br /> G-121501-C1 (07-01) Occurrence Policy Form - California <br /> CNA82011 (04-15) Related Claims Endorsement <br /> G-145184-A (06-03) Policyholder Notice - OFAC Compliance Notice <br /> G-147292-A (03-04) Policyholder Notice - Silica, Mold &Asbestos Disclosure <br /> CNA81753 (03-15) Coverage & Cap on Losses from Certified Acts Terrorism <br /> CNA81758 (01-21) Notice - Offer of Terrorism Coverage & Disclosure of Premium <br /> GSL13424 (05-09) Services to Animals <br /> GSL15563 (02-10) Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs <br /> GSL15564 (10-09) Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion <br /> GSL15565 (03-10) Healthcare Providers Professional Liability Assault Coverage <br /> GSL17101 (02-10) Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br /> CNA80052 (09-14) Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br /> CNA80051 (09-14) Amended Definition of Personal Injury Endorsement <br /> CNA94164 (11-18) Amendment Definition of Claim Endorsement <br /> G-123846-D04 (07-01) California Cancellation and Non-Renewal <br /> CNA79575 (07-14) Exclusion of Cosmetic Procedures <br /> CNA89026 (05-17) Media Expense Coverage <br /> CNA89027 (10-17) Entity Exclusion Endorsement <br /> G-121504-C (07-01) General Liability Form <br /> G-123827-B (07-01)(02) Additional Insured General Liability <br /> G-123828-B (07-01) Certificate Holder <br /> G-141231-A (07-01) Additional Insured Healthcare Entity <br /> PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC <br /> TO YOUR STATE AND YOUR POLICY PERIOD. <br /> For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property &Liability Insurance <br /> Guaranty Association. <br /> For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement <br /> Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. <br /> As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been <br /> applied to your insurance premium and is separately itemized on the Declarations page or billing <br /> instrument attached to your policy, as required KRS. §136.392. <br /> For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. <br /> For FL residents: <br /> Form #:CNA93692 (11-2018) Named Insured: Luis Martinez <br /> Master Policy#: 188711433 Policy#: 0697816243 <br />