HERNANDEZ, FELICE S. 2-2014 - Laserfiche WebLink

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r HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP Catifiratr of X11511rallrr OCCURRENCE POLICY FORM A- io,i - i LA -5 Producer Branch Prefix Policy Number 018098 970 HPG 0619799393 Named Insured and Address: Felice R Hernandez 320 S Pixley St Orange, CA 92868-4030 Medical Specialty: Code: Rehabilitation Counselor 80723 Excludes Cosmetic Procedures H.Irlmw Pravidem Print Date: 1/10/2017 Policy Period from 09/23/16 to 09/23/17 at 12:01 AM Standard Time Program Administered by: Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 119040-1218 1-800-982-9491 www.hpso.com Insurance is provided by: American Casualty Company of Reading, Pennsylvania 333 S, Wabash Avenue, Chicago, IL 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 S25,000 per proceeding S25,000 aggregate Defendant Expense 9enefit $ 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 subfimit Personal Liability $1,000,000 aggregate Total: $ 124.00 Base Premium $124.00 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-1 21503-C G -121501-C1 G -145184-A G -147292-A GSL15563 GSL1 5564 GSL15565 GSL1 7101 GSL13424 CNA80051 CNA80052 G -123846-D04 CNA31753 CNA81758 CNA82011 CNA79575 Keep this document in a safe place, It and proof of payment are your proof of QC coverage. There is no coverage in force unless the premium is paid in full. In order Chairman of the Board Secretary to activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance, Master Policy # 188711433 G-1 41241 -B (03J2010) Coverage Change Date- Endorsement Change Date: