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07/14/2010 10 32 FAH 714 83G 3087 <br />1 <br />TIMG TUSTIN lih004/004 <br />PROFESSIONAL UNDERWRITE[ S <br />LIABILITY INSURANCE COMPA V <br />A TOC Camp, my <br />CLAIMS-MADE <br />MEDICAL PROFESSIONAL LIABILITY POLICY Policy Nuriber: <br />Declarations P93605.. 10 <br />Name and Address of Named Insured: <br />Luis E. Rivera, M.D. <br />800 North Tustin Avert,Ie, Suite A <br />Santa Ana, CA 92705 <br />? J <br />Retroactive Date: September 1, 2005 <br />NOTICE: <br />This is a CLAIMS.-MADE POLICY. Except <br />to such extent as may be provided otherwise herein, Ih :s <br />insurance is limited to liability for only those CLAIMS TI [AT <br />ARE FIRST MADE AGAINST THE INSURED DURING THE <br />POLICY PERIOD. Please read and review the Policy : arefully <br />and discuss with your insurance broker or representat, t:. <br />Vm.IVI t-Cf71 VIJ? -•? <br />(MO. DAY YR.) (MO. DAY YR.) <br />From: 09101109 to: 09101/10 12131 A.M., standard time at the address of the named insured as stated lerein. <br />The insured is engaged in the specialty of Dertaral SVr class 3 -1,1_ :I_ <br />and is duly registered and/or licensed to practice his/her profession under the laws of all jurisdictions in which he/she practices, <br />COVERAGE LIMITS OF LIABILITY PREMIUM - <br />Msdical Professional Liability g 1,000,000.00 Each Claim $ 44,887.00 - <br />$ 10,000.00: Deductible <br />S 3,000,000.00: Aggregate <br />CIGA <br />$ N/A <br />ENDORSEMENTS: $ 44,887.00 <br />W102 Change In 31Peclalty Endorsement <br />W1da Addttional Insured Entity Endaraement <br />W151 Aelnsry Pomennel Endorsement <br />W201 Llmaallon Endorsement - No 3urgaly <br />VM: Inclusion or Praeeduraa Endorsement <br />HV20i Locum Tenons Endorsement <br />W213 Amendment of cancellation Period Endorsement <br />W217 Addhlonal Location Endonsmortt <br />W222 Vicarious Liability Endorsement <br />W305 Change 91 Codueilbk endonement <br />W503 Medical eeerd compliance Endareement <br />WHO eustnesa Assoctates Endorsement <br />This policy is made and accepted subject to the foregoing provisions and stipulations and those hereinafter stated, which are hereby nade <br />a part of this policy, together with such provisions, stipulations and agreements as may be added hereto, as provided In INS Policy. <br />Broker: RGI Inauranc# Services Date of Issue: sa tember 2 2mg <br />23241 South POMte Drive <br />Laguna Mills, CA 92653 <br />Broker Code: 0314 f <br />.DE0001 License Agent or Authorized FtephosentativE