HERNANDEZ, FELICE S. 2-2014 - Laserfiche WebLink

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HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP CNA Certfficate of Insurance 01HPSO HaA,Leao Prmdu.a Ba.izo O,cw6atian• OCCURRENCE POLICY FORM PRODUCER I BRANCH I PREFIX I POLICY NUMBER Policy Period: 018098 1 970 HPG 0619799393-8 From 09/23/15 to 09/23/16 at 12:01 AM Standard Time Named Insured Program Administered by: Healthcare Providers Service Organization Felice R Hernandez 159 E. County Line Road 320 S Pixley St Hatboro, PA 19040-1218 Orange, CA 92868-4030 1-800-982-9491 www.hpso.com Medical Specialty Code Insurance is provided by: Rehabilitation Counselor 80723 Excludes Cosmetic Procedures American Casualty Company of Reading, Pennsylvania 333 South Wabash Avenue Chicago, Illinois 60604 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 & Penalties $ 25,000 per incident $ 25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $124.00 p j////�/� Premium reflects self-employed, part-time rate. ^a^�.�V // Rev f/ U/^�// Policy Forms & Endorsements (Please see attached list for a general deSgflptl,- many common policy forms and endorsements.) G-121500-D 0-121501-Ci G-121503-C CNA82011 G-145184-A G-147292-A CNA81753 CNA81758 GSL13424 GSL15563 GSL15564 GSL15565 GSL17101 CNA80052 CNA80051 G-123846-D04 GNA79575 Chairman of the Board Secretary Keep this Certificate of Insurance in a safe place. This Certificate of Insurance 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 premium in full by the effective date of this Certificate of Insurance. Form #: G-141241-B (3/2010) Master Policy: 188711433 HP50-505-N-0014-H1 20150924-761