Laserfiche WebLink
HEALTHCARE PROVIDERS SERVICE <br />CNA <br />ORGANIZATION PURCHASING GROUP INHPSO <br />llgila0efl9n,;,a,pa <br />'ante <br />(Tertlf sate of 3hou Francine R. <br />OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM Villareal Date: 202108.0914:45.49 <br />-07" <br />Print Date: 7/29/2021 <br />The application for the Policy and any and allsupplementary information, materials, and statements submitted therewith shall <br />be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as <br />If physically attached. <br />PRODUCER BRANCH PREFIX <br />POLICY NUMBER POLICY PERIOD <br />018098 970 HPG <br />0697816243 <br />From: 12/10/20 at 02:09 PM ET to 12/10/21 at 12:0 AAM Std Time <br />Named Insured and Address: <br />Program Administered by: <br />Luis Martinez <br />Healthcare Providers Service Organization <br />301 W 2nd St Apt 241 <br />1100 Virginia Drive, Suite 250 <br />Santa Ana, CA 92701-5295 <br />Fort Washington, PA 19034 <br />1-800-982-9491 <br />www.hpso.com <br />Medical Specialty: <br />Code: <br />Insurance Provided by: <br />Alcohol/Drug Counselor <br />80723 <br />American Casualty Company of Reading, Pennsylvania <br />151 N. Franklin Street <br />Excludes Cosmetic Procedures <br />Chicago, IL 50606 <br />Professional Liability $ 1,000,000 each claim $ 3,000,000 aggregate <br />Your professlonaI (lability limits shown above Include the following: <br />* Good Samaritan Liability * Malplacement Liability <br />* Personal Injury Liability <br />* Sexual Misconduct Included in the PL limit shown above subject <br />to $ 25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />$ 25,000 <br />per proceeding <br />$ 25,000 <br />aggregate <br />Defendant Expense Benefit <br />$ 1,000 <br />per day limit <br />$ 25,000 <br />aggregate <br />Deposition Representation <br />$ 10,000 <br />per deposition <br />$ 10,000 <br />aggregate <br />Assault <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments <br />$ 25,000 <br />per person <br />$ 100,000 <br />aggregate <br />First Aid <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />Damage to Property of Others <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />Information Privacy (HIPAA) Fines and Penalties <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />Media Expense <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />General Liability <br />General Liability $1,000,000 each claim / $2,000,000 aggregate <br />Fire & Water Legal Liability Included in the GL limit shown above subject to $260,000 aggregate sublimit <br />Personal Liability $1,000,000 aggregate <br />Total $ 465.00 <br />Base Premium $465.00 <br />Premium reflects Self Employed , Part Time <br />Policy Forms and Endorsements (Please see attached list of policy forms and endorsements) <br />Chairman of the Board <br />Secretary <br />Keep this Certificate of Insurance in a safe place. It and proof of payment are your proof of coverage <br />force unless the premium is paid in full. To activate your coverage, please remit premium in full by <br />Certificate of Insurance. <br />Coverage Change Date: 7/29/2021 Endorsement Date: 7/29/2021 <br />CNA93692 (11-2018) <br />RiakManagemenfDitielon <br />REVIEWED&APPRDv¢)BY: <br />AwfRhL�r F'FAA�d�r� 4 R, if <br />Rulc Management A[tily5[ <br />