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<br />Healthcare Providers Service <br />Group NHPS0 <br />CNA '} "JJ??Orga jniizatff??ion Purchasing <br />H„k6<ur P, <br />o. ikn &..k, Ord.^uae.,, <br />??.d` -Y ? ? V Y-V of ;4juOuran. <br />OCCURRENCE POLICY FORM <br />Producer Branch Prefix Policy Number Policy Period <br /> from: 12:01 AM Standard Time on:. 08/01/10 <br />018098 970 HPG 029875500 -8 to: 1 AM Standard on, -01/11___ <br />Named Insured and Address Program Adininistrator <br /> Healthcare Providers Service Organization <br /> <br />BOSCH <br />A <br />VIESLEY <br />159 East County Line Road <br />1000 E <br />SANTA TA AN AA BLVD STE 200 <br />1000 E <br />PA 19040-1218 <br />Hatboro <br />SANTA ANA CA 92701-3900 , <br />Medical Specialty: Code: Insurance Provided by <br />Marriage/Family Counselor 80723 <br />American Casualty Company of Reading, Pennsylvania <br /> 333 S. Wabash Avenue Chicago, IL 60604 <br />COVERAGE PARTS LIMITS OF LIABILITY <br />B. Coverage Extensions <br />Damage of Property o <br />C. WORKPLACE LIABILITY <br />10,000.00 per incident <br />C. does not apply if Coverage <br />i $10,000.00 <br />D, is made part of this <br />D. GENERAL LIABILITY <br />Personal Liabili <br />D. does not apply if Covera <br />C. is made part of this <br />None <br />Total $240.00 Premium reflects self-employed, fill-time rate. <br />Policy forms and endorseinents attached at inception QUESTIONS? CALL: 1-800-982-9491 <br />G-121500-D G-121501-C1 G-121503-C G-145184-A G-147292-A GSL3886 GSL3908 G-123846-D04 <br />G-123828-B <br />APPROVED AS TO FORM <br />LISA E. STO,RCK <br />Master Policy: 188711433 <br />Attoney / L <br />Acci?-,tant City <br />Keep this document in a safe place, This and <br />Cc your cancelled check act t as proof of coverage. <br />Chairman of the Board Secretary <br />G-141241-A (7/2001) 401 XX 0000008-R 100524 RENHCP 12108 R1H8HM 10144