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CNA HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP WHPSO Certificate of 1twurance OCCURRENCE POLICY FORM Print Date: 12/17/2018 �Iif Pro r Branch Prefix Policy Number Policy Period 018098 970 HPG 0619799393 from 09/23/18 to 09/23/1 gat 12:01 AM Standard Time Named Insured and Address: Program Administered by: Felice R Hernandez Healthcare Providers Service Organization 320 S Pixley St 1100 Virginia Drive, Suite 250 Orange, CA 92868-4030 Fort Washington, PA 19034 1-800-982-9491 www.hpso.com Medical Specialty: Code: Insurance is provided by: Rehabilitation Counselor 80723 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Excludes Cosmetic Procedures Professional Liability $1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $100,000 aggregate First Aid $ 10,000 per incident $10,000 aggregate Damage to Property of Others $ 10,000 per incident $10,000 aggregate Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire & Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $ 120.00 Base Premium $120.00 Premium reflects Self Employed , Part Time Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G -121500-D G -121503-C G -121501-C1 G -145184-A G -147292-A GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G -123846-D04 CNA81753 CNA81758 CNA82011 CNA79575 Keep this document in a safe place. It and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit Chairman of th Board Secretary premium in full by the effective date of this Certificate of Insurance. Master Policy # 188711433 G -141241-B (03/2010) Coverage Change Date: Endorsement Change Date: