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iat 7- <br />HEALTHCARE PROVIDERS SERVICE <br />CNA ORGANIZATION PURCHASING GROUP <br />Catificaxt of hissurart ®.H?I'so <br />OCCURRENCE POLICY FORM <br />PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br />01 8998 97Q HPG' t}298755008-ti. From 08/01/11 to 08/01/12 at 12:01 AM Standard Time <br />Named Insured Program Administered by: <br />Healthcare Providers Service Organization <br />Wesley A. Bosch 159 East County Line Road <br />1000 E. Santa Ana Blvd., Ste. 200 Hatboro, PA 19040-1218 <br />Santa Ana, CA 92701-3900 1-800-982-9491 <br />www.hpso.com <br />Medical Specialty Code Insurance is provided by: <br />Marriage/Family Counselor 80723 American Casualty Company of Reading, Pennsylvania <br />333 South Wabash Avenue Chicago, Illinois 60604 <br />Professional Liability $1,000,000 each claim $3,000,000 aggregate <br />Your professlonaf Ilability limits shown above Include the following: <br />• Good Samaritan Liability • Malplacement Liability • Personal Injury Liability <br />• Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection $25,000 per proceeding $25,000 aggregate <br />Defendant Expense Benefit $1,000 per day limit $25,000 aggregate <br />Deposition Representation $10,000 per deposition $10,000 aggregate <br />Assault $25,000 per incident $25,000 aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments $25,000 per person $100,000 aggregate <br />First Aid $10,000 per incident $10,000 aggregate <br />Damage of Property of Others $10,000 per incident $10,000 aggregate <br />Information Privacy (HIPAA) Fines & Penalties $25,000 per incident $25,000 aggregate <br />Workplace Liability <br />Workplace Liability Included in Professional Liability Limit shown above <br />Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sub limit <br />Personal Liability $1,000,000 aggregate <br />Pty iyl <br />Total: $240.00 APPReVED AS TO <br />Premium reflects self-employed, full-time rate. <br />L,7 <br />LISA E. STORCK <br />26rs I5g City Attorney <br />Policy Forms & Endorsements (Please see attached list for a generaldescriptbnof thep its that mayorrrayrrotapi>ytothis poky) <br />G-121500-D G-121501-C1 G-121503-C G-145184-A G-147292-A GSL3886 GSL3908 GSL13424 GSL15563 <br />GSL15564 GSL15565 GSL17101 G-123846-D04 G-1 23828-B <br />?" Cc kwc?- ?P? A V-1/411 <br />Chairman of the Board Secretary <br />Keep this Certificate of Insurance in a safe place. This Certificate of Insurance and proof of payment are your proof of coverage. <br />There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit premium in full by <br />the effective date of this Certificate of Insurance. <br />G-141241-B (312010) Master Policy: 188711433 <br />401 XX 0000276-R 110523 H70910 RlH6HM 11143