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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 <br />professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms & <br />endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be <br />available in all states. All products and services are subject to change without notice. <br />Think Green —expanded definitions and copies of these policy forms and endorsements are available online at <br />www.hpso.com/policyforms <br />COMMON POLICY FORMS & ENDORSEMENTS <br />FORM # <br />DESCRIPTION <br />G -121500-D <br />Common Policy Conditions <br />G -121503-C <br />Workplace Liability Form <br />G -121501-C1 <br />Occurrence Policy Form - California <br />G -145184-A <br />Policyholder Notice - OFAC Compliance Notice <br />G -147292-A <br />Policyholder Notice - Silica, Mold & Asbestos Disclosure <br />GSL15563 <br />Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs <br />GSL15564 <br />Sexual Misconduct Sublinnits of Liability Professional Liability & Sexual Misconduct Exclusion <br />GSL1 5565 <br />Healthcare Providers Professional Liability Assault Coverage <br />GSL1 7101 <br />Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br />GSL1 3424 <br />Services to Animals <br />CNA80051 <br />Amended Definition of Personal Injury Endorsement <br />CNA80052 <br />Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />G -123846-D04 <br />California Cancellation and Non -Renewal <br />CNA81753 <br />Coverage & Cap on Losses from Certified Acts Terrorism <br />CNA81758 <br />Notice - Offer of Terrorism Coverage & Disclosure of Premium <br />CNA82011 <br />Related Claims Endorsement <br />CNA79575 <br />Exclusion of Cosmetic Procedures <br />PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC <br />TO YOUR STATE AND YOUR POLICY PERIOD. <br />For NJ' residents: The PLICA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance <br />Guaranty Association. <br />For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement <br />Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which <br />includes charges at a municipality and/or county level, <br />For WV residents: The surcharge, shown on the Certificate of Insurance is the WV Premium Surcharge. <br />For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL insurance Guaranty Association <br />- 2012 Regular Assessment, <br />Fo,rrn#: G-1 41241 -B (03/2010) Named insured- Felice R Hernandez <br />Master Policy* 188711433 Policy#: 0619799393 <br />