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DECLARATIONS <br />Policy Number AHY-754318001 _ Renewal Of. New <br />SECTION I <br />Item <br />1. Named Insured: Felice Hernandez <br />2.320 S. Pixley Street <br />Mailm Address: -..._.........._. _ _,.........._ _.. _...-..._._--- <br />g , <br />Orange, CA 92868 <br />3. Policy Period: From: 08/21/2014 To: 08/21/2015 <br />12:01 A M Standard Time At Location of Designated, Premises <br />4. Business or Profession: Affiliation: 3471. - Rehabilitation Counselors Prof Liability <br />Rehabilitation Counselor <br />5. The Named Insured is a(n): �❑ Parmexslup Corporation �� Ind v dual <br />❑ Sole Proprietor (with employees) ❑ Other: <br />This policy is made and accepted subject to the printed conditions of this policy together with the provisions, <br />stipulations and agreements contained in the following form(s) or endorsement(s): HCPL-2037 (11/09), HCPL-2038 (11/09) <br />HCPI. 8020 (Ed. 12/10), <br />HCPI-2037-9000 CA (11/09) HCPL-2151 (11/09), OFAC (08/09), <br />SECTION II <br />ItemCOVERAGE Premium <br />...... _._ ..._,_.__.._.. _. _ .. -- ----. _ -_ ..---_.... .---......_.. ..... ........--.. ......_.._...... ..-.... ------- <br />.. <br />A. Professional Liability [X] $205 00 <br />B. General Liability [ ] <br />Terrorism Risk Insurance Act [ ] $0.00 <br />C. Endorsements [ ] <br />TOTAL: $205.00 <br />LIMITS OF LIABILITY <br />-.__.._.. .-._......._.. _ _ ..._...._._ ... ._._-.._ _...- ._._.. ,.....---._. _ ............ ..___..__...... _ ....__...... --------- ........ ........... <br />. <br />$1,000,000 Each Incident and Each Occurrence $3,000,000 AP,Qmgate <br />SECTION III <br />SU PPI.FMENTARYPAYMENTS <br />A. First Party Assault <br />B. Licensing Board Reimbursement <br />C. Wage Loss and Expense <br />D. Deposition Expense <br />E. First Aid Reimbursement <br />Representative Agent: Mercer Consumer, a service of <br />Mercer Health & Benefits Administration LLC <br />P.O. Box 14576 <br />Des Moines, IA 50306-3576 <br />1 1-800-503-9230 <br />HCPL-2037D (11/09) <br />10 <br />liberty <br />lttternatitartal <br />Underw ritert;,. <br />Healthcare Professional Liability <br />°°° ... <br />LIBERTY INSURANCE UNDERWRITERS INC. <br />(A Stock Imumnm Company, hereinafter the "Compmn <br />55 Water Street,1 rh F our <br />New Y rk, NY 1 041 <br />DECLARATIONS <br />Policy Number AHY-754318001 _ Renewal Of. New <br />SECTION I <br />Item <br />1. Named Insured: Felice Hernandez <br />2.320 S. Pixley Street <br />Mailm Address: -..._.........._. _ _,.........._ _.. _...-..._._--- <br />g , <br />Orange, CA 92868 <br />3. Policy Period: From: 08/21/2014 To: 08/21/2015 <br />12:01 A M Standard Time At Location of Designated, Premises <br />4. Business or Profession: Affiliation: 3471. - Rehabilitation Counselors Prof Liability <br />Rehabilitation Counselor <br />5. The Named Insured is a(n): �❑ Parmexslup Corporation �� Ind v dual <br />❑ Sole Proprietor (with employees) ❑ Other: <br />This policy is made and accepted subject to the printed conditions of this policy together with the provisions, <br />stipulations and agreements contained in the following form(s) or endorsement(s): HCPL-2037 (11/09), HCPL-2038 (11/09) <br />HCPI. 8020 (Ed. 12/10), <br />HCPI-2037-9000 CA (11/09) HCPL-2151 (11/09), OFAC (08/09), <br />SECTION II <br />ItemCOVERAGE Premium <br />...... _._ ..._,_.__.._.. _. _ .. -- ----. _ -_ ..---_.... .---......_.. ..... ........--.. ......_.._...... ..-.... ------- <br />.. <br />A. Professional Liability [X] $205 00 <br />B. General Liability [ ] <br />Terrorism Risk Insurance Act [ ] $0.00 <br />C. Endorsements [ ] <br />TOTAL: $205.00 <br />LIMITS OF LIABILITY <br />-.__.._.. .-._......._.. _ _ ..._...._._ ... ._._-.._ _...- ._._.. ,.....---._. _ ............ ..___..__...... _ ....__...... --------- ........ ........... <br />. <br />$1,000,000 Each Incident and Each Occurrence $3,000,000 AP,Qmgate <br />SECTION III <br />SU PPI.FMENTARYPAYMENTS <br />A. First Party Assault <br />B. Licensing Board Reimbursement <br />C. Wage Loss and Expense <br />D. Deposition Expense <br />E. First Aid Reimbursement <br />Representative Agent: Mercer Consumer, a service of <br />Mercer Health & Benefits Administration LLC <br />P.O. Box 14576 <br />Des Moines, IA 50306-3576 <br />1 1-800-503-9230 <br />HCPL-2037D (11/09) <br />