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L <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROUP <br />(Certifli of Inqurflure <br />OCCURRENCE POLICY FORM <br />Print Date: 9/13/2017 <br />Producer Branch Prefix <br />Policy Number Policy Period <br />018098 970 HPG <br />0619799393 from 09/23/17 to 09/23/18 at 12:01 AM Standard Time <br />Named Insured and Address: <br />Program Administered by: <br />Felice R Hernandez <br />Healthcare Providers Service Organization <br />320 S Pixley St <br />159 E. County Line Road <br />Orange, CA 92868-4030 <br />Hatboro, PA 19040-1218 <br />1-800-982-9491 <br />www.hpso,com <br />Medical Specialty: <br />Code: Insurance is provided by: <br />Rehabilitation Counselor <br />80723 American Casualty Company of Reading, Pennsylvania <br />333 S. Wabash Avenue, Chicago, IL 60604 <br />Excludes Cosmetic Procedures <br />Professional Liability <br />$1,000,000 each claim $ 3,000,000 aggregate <br />Your professional liability limits shown above include the following, <br />* Good Samaritan Liability <br />* Malplacement Liability * Personal Injury Liability <br />Sexual Misconduct Included <br />in the PL limit shown above subject to $ 25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />$25,000 per proceeding $25,000 aggregate <br />Defendant Expense Benefit <br />$ 1,000 per day limit $ 25,000 aggregate <br />Deposition Representation <br />$ 10,000 perdepusition $ 10,000 aggregate <br />Assault <br />$ 25,000 per incident $ 25,000 aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments <br />$ 25,000 per person $ 100,000 aggregate <br />First Aid <br />$ 10,000 per Incident $ 10,000 aggregate <br />Damage to Property of Others <br />$ 10,000 per incident $ 10,000 aggregate <br />Information Privacy (HIPAA) Fines <br />and Penalties $ 25,000 per incident $ 25,000 aggregate <br />Workplace Liability <br />Workplace Liability <br />Included in Professional Liability Limit shown above <br />Fire & Water Legal Liability <br />Included in the PL limit shown above subject to $150,000 aggregate sublimil <br />Personal Liability <br />$1,000,000 aggregate <br />Total: $ 124.00 <br />Base Premium $124.00 <br />Premium reflects Self Employed , Part Time l C��^ ^ 10_ ( 1 <br />Policy Forms & Endorsements (Please see attached fist for a general description of many common policy forms and <br />endorsements.) <br />G -121500-D G -121503-C G -121501-C1 G -145184-A G -147292-A GSL15563 GSL15564 <br />GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G -123846-D04 CNA81753 <br />CNA81758 ONA82011 CNA79575 <br />Keep this document in a safe place. It <br />(� p and proof of payment are your proof <br />\� Ij�'",Vp_/�V, II"�V C11• tv1 �` coverage. There is no coverage in force <br />v unless the premium is paid in fuX in order <br />to activate your coverage, please remit <br />Chairman of th Board Secretary premium in full by the effective date of <br />this Certificate of insurance. <br />Master Policy # 188711433 <br />G -141241-B (03/2010) Coverage Change Date: Endorsement Change Date: <br />