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POLICY FORMS & ENDORSEMENTS <br />The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. <br />State specific policy forms and endorsements are not Included in the list below. Should you require descriptions or samples of these documents, please <br />visit us online at www.hpso.com/policyforms. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your <br />state and your policy period. All products and services may not be available in all states and may be subject to change without notice. <br />Think Green — expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms. <br />COMMON POLICY FORMS & ENDORSEMENTS <br />FORM # DESCRIPTION <br />G -121500-D <br />Common Policy Conditions <br />G -121501 -Cl <br />Occurrence Policy Form - California <br />G -121503-C <br />Workplace Liability Form <br />CNA82011 <br />Healthcare Providers Related Claims Endorsement <br />G-1 45184-A <br />Policyholder Notice - OFAC Compliance Notice <br />G -147292-A <br />Policyholder Notice - Silica Mold & Asbestos Disclosure <br />CNA81753 <br />Cap on Losses from Certified Acts of Terrorism <br />CNA81758 <br />Offer of Terrorism Coverage - Disclosure of Premium <br />GSL13424 <br />Services to Animals <br />GSL15563 <br />Information Privacy Coverage Endorsement HIPAA Fines Penalties & Notification Costs <br />GSL15564 <br />Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion <br />GSL15565 <br />Healthcare Providers Professional Liability Assault Coverage <br />GSL17101 <br />Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br />CNA80052 <br />Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />CNA80051 <br />Amended Definition of Personal Injury Endorsement <br />G -123846-D04 <br />California Cancellation and Non -Renewal <br />CNA79575 <br />Exclusion of Cosmetic Procedures <br />PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND <br />YOUR POLICY PERIOD. <br />Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner's status <br />change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Healthcare <br />Providers Service Organization for details. <br />Form #: G -141241-B <br />Master Policy #: 188711433 <br />H10412 <br />Named Insured: Felice R Hernandez <br />Policy #: 0619799393-8 <br />