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HomeMy WebLinkAboutHERNANDEZ, FELICE S. 2-2014LOH t4�lA�1Ci:ON BILE N�TIL WSUHAnCW[XPIH1 Ei -Ht(OF COUNG0.. CONSULTANT AGREEMENT A-2014-143 THIS AGREEMENT, made and entered into this 1 `t day of July, 2014 by and between Felice Stinson Hernandez (hereinafter "Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and taws of the State of California (hereinafter "City. RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of counseling and/or instructional services encompassing the fields of anger management, stress reduction, conflict management/resolution, domestic violence avoidance, chemical dependency, life skills/family issues and community resources to the inmates housed at the Santa Ana City jail. B. Consultant represents that he is able and willing to provide such services to the City. C, In undertaking the performance of this Agreement, Consultant represents that he is knowledgeable in his field, and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant and City shall perfornz those services as set forth in Exhibit A to this Agreement which include counseling and/or instructional services to inmates in the areas ofanger agement, stress reduction, conflict management/resolution, domestic violence avoidance, chemical depe ency, life skills/faro ly issues and community resources. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for services an hourly rate of thirty seven dollars ($37.00) for all scheduled instructional and counseling sessions. The total sum to be expended shall not exceed $75,000 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City, 3. TERM This Agreement shall commence on the date first written above and terminate on June 30, 2017 unless terminated earlier in accordance with Section 12, below. 4. ,INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer-employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social, security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Stich insurance shall include coverage for owned, hired and non - owned automobiles. b. Worker's Compensation Insurance. In accordance with the provisions of Section 3700 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. Q. If Consultant is or employs a licensed professional such as an architect or engineer: Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim, d. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (iii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. e. If Consultant fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City, 8. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified render this Agreement. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be, properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Cleric of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702.1988 Fax 714-647-6956 With courtesy copies to: and Santa Ana City Jail — Support Manager of Jail Operations City of Santa Ana 20 Civic Center Plaza M-88 P.O. Box 1988 Santa Ana, California 92702 Fax 714- 647.8116 City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 Fax 714- 647-6515 To Consultant: Felice Stinson Hernandez %aro x-1138 South Pixley Street Al 00- Orange, California 92868 A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and. Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant, The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by the City with or without cause upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the City Manager may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 13, DISCREVIINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment rotated activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. JURISDICTION - VENUE This Agroernent has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 15. PROFESSIONAL. LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all othor governmental agencies. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 16, MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attgmoy' a fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn, b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: -Tyl o -p- P Al, MARIA D. HUIZAR Clork of the, Council APPROVED AS TO FORM: SOMA R. CARVALHO City Attorney /'Oh ca :!6k4 ity Attorney RECON END i F i;2APPROVAL: CARLOSROJAS Chief of Police CITY OF SANTA ANA 7:j2:�) /' DAVID CAVAZOS City Manager EXHIBIT A SCOPE OF SERVICES 1. CITY'S Responsibilities: The CITY shall provide the following assistance to CONSULTANT: a. Identify a contact person who shall be responsible for scheduling and coordinating the services to be provided by CONSULTANT. The subject matter, the number of hours and the scheduling of hours shall be at the sole discretion of the CITY. b. Schedule and record CONSULTANT'S time worked during meetings, instruction and counseling sessions. c. Provide an adequate facility that will allow CONSULTANT to perform the services required under this agreement in an efficient and timely manner. d. Provide prompt notice to the CONSULTANT whenever the CITY observes or otherwise becomes aware of any defect in the services provided under the terms of the agreement. 2. CONSULTANT'S Responsibilities: CONSULTANT shall provide the following services to CITY: a. Deliver instructional and/or counseling services in the following program areas to selected inmates: (1) anger management (2) stress reduction (3) conflict management/resolution (4) domestic violence (S) chemical dependency (6) life skills/family issues (7) community resources b. Coordinate with CITY staff to facilitate delivery of program material. c. Collect specific diagnostic and statistical information regarding inmates in attendance and program material. d. Assign inmates tasks to perform and goals to reach in relation to the program material. e. Provide inmates in attendance with referrals to other agencies and community resources that can provide additional instruction and/or counseling as follow-up to the program material already delivered. Client # 986851 MEMORANDUM OF INSURANCE ate Issued 08/21 /2014 Producer This memorandum is issued as a matter of information Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 only and confers no rights upon the holder. This memorandum does not amend, extend or alter coverages afforded by the Certificate listed below. Des Moines, IA 50306-3576 Company Affording Coverage Liberty Insurance Underwriters Inc 1-800-503-9230 Insured Felice Hernandez 320 S. Pixley Street Orange CA 92868 This is to certify that the Certificate listed below has been issued to the insured named above for the policy period indicated not withstanding any requirement, term or condition of any contract or other document with respect to which this emorandum may be issued or may pertain, the insurance afforded by the Certificate described herein is subject to all the terms, exclusions and conditions of such Certificate. The limits shown may have been reduced by paid claims. Type of Insurance Certificate Number Effective Date Expiration Date Limits Professional Liability RehabProf SE Rehabilitation Counselor AHY-754318001 08/21/2014 08/21/2015 PerIncident/ Occurrence $1,000,000 Annual Aggregate $3 000 000 PROOF OF INSURANCE Memorandum Holder: Should the above describe Certificate be cancelled PROOF OF COVERAGE ONLY before the expiration date thereof, the issuing company ill endeavor to mail 30 days written notice to the Memorandum Holder named to the left, but failure t ail such notice shall impose no obligation or liability PROVED AS TO FORN1i I, k _.S_� of any kind upon the company, its agents o representatives. Authorized Representative Laeara A, Rossini Mark Assistant City Attorney ""Brppostowitz Mercer Consumer, a service of Mercer Health & Benefits Administration I.I.C. In CA d/b/a Mercer Health & Benefits Insurance Services LLC. CA Lie.# OG39709 Liberty Healthcare Professional Liability Unde . LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hucinafter the "Compann ENDORSEMENT NO. Effective Date: 08/21/2014 Policy Number: AHY-754318001 Issued To: Felice Hernandez Return Premium ❑ Additional Premium ❑ $ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COVERED OCCUPATIONS ENDORSEMENT The business, occupation and/or profession shown in the Declarations of this policy is amended to include the following: Occupation Covered Occupation Covered Primary Professional Designation Rehabilitation Counselor Registered Nurse Employee Other Owners Other Employees Rehab Asst,Counselor,Thempist Registered Nurse -FT Employee Registered Nurse -PT Rehabilitation Assistant -FT Rehabilitation Assistant -PT Rehabilitation Counselor -FT Rehabilitation Counselor -PT I Rehabilitation Therapist -FT Rehabilitation Therapist -PT ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. APPROVED AS TO FORM 1 HCPI-8020 (Ed, 04/14) Q A,1,ia— Laura A. Rossini Assistant City Attorney DECLARATIONS Policy Number AHY-754318001 _ Renewal Of. New SECTION I Item 1. Named Insured: Felice Hernandez 2.320 S. Pixley Street Mailm Address: -..._.........._. _ _,.........._ _.. _...-..._._--- g , Orange, CA 92868 3. Policy Period: From: 08/21/2014 To: 08/21/2015 12:01 A M Standard Time At Location of Designated, Premises 4. Business or Profession: Affiliation: 3471. - Rehabilitation Counselors Prof Liability Rehabilitation Counselor 5. The Named Insured is a(n): �❑ Parmexslup Corporation �� Ind v dual ❑ Sole Proprietor (with employees) ❑ Other: This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s): HCPL-2037 (11/09), HCPL-2038 (11/09) HCPI. 8020 (Ed. 12/10), HCPI-2037-9000 CA (11/09) HCPL-2151 (11/09), OFAC (08/09), SECTION II ItemCOVERAGE Premium ...... _._ ..._,_.__.._.. _. _ .. -- ----. _ -_ ..---_.... .---......_.. ..... ........--.. ......_.._...... ..-.... ------- .. A. Professional Liability [X] $205 00 B. General Liability [ ] Terrorism Risk Insurance Act [ ] $0.00 C. Endorsements [ ] TOTAL: $205.00 LIMITS OF LIABILITY -.__.._.. .-._......._.. _ _ ..._...._._ ... ._._-.._ _...- ._._.. ,.....---._. _ ............ ..___..__...... _ ....__...... --------- ........ ........... . $1,000,000 Each Incident and Each Occurrence $3,000,000 AP,Qmgate SECTION III SU PPI.FMENTARYPAYMENTS A. First Party Assault B. Licensing Board Reimbursement C. Wage Loss and Expense D. Deposition Expense E. First Aid Reimbursement Representative Agent: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 Des Moines, IA 50306-3576 1 1-800-503-9230 HCPL-2037D (11/09) 10 liberty lttternatitartal Underw ritert;,. Healthcare Professional Liability °°° ... LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Imumnm Company, hereinafter the "Compmn 55 Water Street,1 rh F our New Y rk, NY 1 041 DECLARATIONS Policy Number AHY-754318001 _ Renewal Of. New SECTION I Item 1. Named Insured: Felice Hernandez 2.320 S. Pixley Street Mailm Address: -..._.........._. _ _,.........._ _.. _...-..._._--- g , Orange, CA 92868 3. Policy Period: From: 08/21/2014 To: 08/21/2015 12:01 A M Standard Time At Location of Designated, Premises 4. Business or Profession: Affiliation: 3471. - Rehabilitation Counselors Prof Liability Rehabilitation Counselor 5. The Named Insured is a(n): �❑ Parmexslup Corporation �� Ind v dual ❑ Sole Proprietor (with employees) ❑ Other: This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s): HCPL-2037 (11/09), HCPL-2038 (11/09) HCPI. 8020 (Ed. 12/10), HCPI-2037-9000 CA (11/09) HCPL-2151 (11/09), OFAC (08/09), SECTION II ItemCOVERAGE Premium ...... _._ ..._,_.__.._.. _. _ .. -- ----. _ -_ ..---_.... .---......_.. ..... ........--.. ......_.._...... ..-.... ------- .. A. Professional Liability [X] $205 00 B. General Liability [ ] Terrorism Risk Insurance Act [ ] $0.00 C. Endorsements [ ] TOTAL: $205.00 LIMITS OF LIABILITY -.__.._.. .-._......._.. _ _ ..._...._._ ... ._._-.._ _...- ._._.. ,.....---._. _ ............ ..___..__...... _ ....__...... --------- ........ ........... . $1,000,000 Each Incident and Each Occurrence $3,000,000 AP,Qmgate SECTION III SU PPI.FMENTARYPAYMENTS A. First Party Assault B. Licensing Board Reimbursement C. Wage Loss and Expense D. Deposition Expense E. First Aid Reimbursement Representative Agent: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 Des Moines, IA 50306-3576 1 1-800-503-9230 HCPL-2037D (11/09) NOTICE Claim Reporting Instructions Intercare Insurance Services, Inc. r Intercare") is the claims administrator for matters covered under your Professional Liability Insurance policy. A claim must be reported to Intercare for assignment to a Claims Professional. Please contact Intercare at the following address and/or telephone number: Intercare Insurance Services, Inc. P.O. Box 52810 Bellevue, WA 98015 Toll Free Number: 1-877-658.0731. Main Local Number: 425-636-1000 Fax Number: 1-877-299-3282 Email to: claimsmanagement@intercareins.com This means you have a simple way to notify us of a claim in accordance with the terms and conditions of your policy. Please refer to your policy for definition of a claim and reporting obligations. 100785(12/08) 00 MERCER August 21, 2014 Felice Hernandez 320 S. Pixley Street Orange, CA 92868 Re: Allied Health Professional Liability Customer Number: 986851 Policy Number: AHY-754318001 Expiration Date: 08/21/2015 Dear Felice R Hernandez, Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 Des Moines, IA 50306-3576 www.pmliability.com I am pleased to enclose your insurance policy through the Liberty Insurance Underwriters Inc. Please review the material carefully and take specific notice of any endorsements to the policy. These policy documents should be kept with your important papers. Please note the important information below: Address or Mid -Term Changes: Any change of address or request for mid-term change should be sent to the following address to assure timely receipt of future notices. All requests must be signed and dated by the policy holder. Also note that requests for mid-term changes to your coverage must be approved by an underwriter prior to binding coverage. Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 Des Moines, IA 50306-3576 Fax:515-365-6338 Phone: 1.800-503-9230 If you have any questions, please contact our office Monday through Friday from 8:15 a.m. to 5:00 p.m. (CT). Thank you for the opportunity to serve your insurance needs. Sincerely, Mark Brostowitz Principal Mercer Consumer Enclosure Rehabilitation Prof Self Employed New Submission MARSH & McLENNAN TALENT • HEALTH • RETIREMENT • INVESTMENTS COMPANIES Liberty_ PROFESSIONAL LIABILITY "'PInternational Ilradea�avrllers. Effective Date: Policy Number: Issued To: LIBERTY INSURANCE UNDERWRITERS INC. (A New York Stock Insurance Company, hereinafter the "Insurer") 08/21/2014 AHY-754318001 Felice Hernandez ENDORSEMENT NO. [ ] THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. U.S. ECONOMIC AND TRADE SANCTIONS ENDORSEMENT Whenever coverage provided by this policy would be in violation of any U.S. economic or trade sanctions such as, but not limited to, those sanctions administered and enforced by the U.S. Treasury Department's Office of Foreign Assets Control ('OFAC'), such coverage shall be mill and void. Similarly, any coverage relating to or referred to in any certificates or other evidences of insurance or any claim that would be in violation of U.S. economic or trade sanctions as described above shall also be null and void. 1 OFAC 08/09 Liberty Inte�rnatitn 2d Healthcare Professional Liability Underwriters. Subject to the foregoing, the total amounts payable under this extension shall not exceed $75,000 for all persons who sustain Bodily Injury. III. DAMAGE TO PROPERTY OF OTHERS The Company will pay, in addition to the applicable Limit of Liability, rip to $500 for all Damage to the property of others that is caused by the Insured during the Policy Period. The Company will not pay for damage to the property of others if such damage arises out of.- A. f A. any act or omission with regard to any premises, other than your residence premises, which is owned, rented or controlled by an Insured; or B. the Insured's ownership, use, care, or entrustment to others of an Automobile, Mobile Eq ipment, watercraft or aircraft. Within sixty (60) days from the date of loss, the Insured must submit a sworn statement of such loss to the Company. The Insured must also exhibit the damaged property if such property is in the Insured's possession and/or control. IV. EXCLUSIONS DELETED Solely as respects the COVERAGES afforded by this COVERAGE PART, Exclusions 3, 4, 5,14,15 and 16 do not apply. V. EXCLUSIONS ADDED Solely as respects the COVERAGES afforded by this COVERAGE PART, this insurance does not apply: A. to Claims brought by, or on behalf of any: 1. Insured; 2. regular resident of premises owned by or rented to the Named Insured; or 3. spouse, child, parent, or other relative of the Named Insured; B. to Claims brought against the Insured arising out of, in whole or part, the conduct of any trade, business, employment, profession or occupation; C. to Bodily Injury and Personal Injury to any employee of the Insured while engaged in the business, other than the domestic employment, of the Insured or to any obligation for which the Insured may be held liable under any workers' compensation law or in respect to an Occurrence arising from the use, including loading and unloading, of an Automobile, recreational motor vehicle, tractor or trailer owned or operated by or on behalf of the Insured, arising from the use, including loading and unloading, of any aircraft or watercraft of any nature, or caused by any person employed by the Insured while engaged in the maintenance or use of such Automobile, tractor, trailer, aircraft or watercraft. A recreational motor vehicle means a golf cart or snowmobile or any other land motor vehicle designed for recreational use off public roads whether or not subject to motor vehicle registration; but this exclusion does not apply to golf carts while used for golfing purpose. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. HCPL-2151 (Ed. 11/09) liberty Internatimal Healthcare Professional Liability It, Underwriters. LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hereinafter t1w "Company') ENDORSEMENT NO.[ ] Effective Date: 08/21/2014 Policy Number! AHY-754318001 Issued To: Felice Hernandez THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. INDIVIDUAL PRACTITIONER COVERAGES This policy is amended by the addition of the following.- 1. ollowing: I. SUPPLEMENTAL LIABILITY The Company will pay on behalf of the Insured all sums which the Insured shall become legally obligated to pay as Damages because of Bodily Injury or Property Damage to which this insurance applies caused by an Occurrence, during the Policy Period. The Limit of Liability stated in the Declarations as applicable to "each Incident" or "each Occurrence" is the limit of the Company's liability for all Damages for each Occurrence covered by the policy. This Limit of Liability is separate from the Limit of Liability applicable to COVERAGES A. PROFESSIONAL LIABILITY COVERAGE and B. GENERAL LIABILITY COVERAGE, of the policy. However, all Claims arising from the same or related Occurrence shall be considered a single Claim for the purpose of this insurance and shall be subject to the same Limit of Liability, The Limit of Liability stated in the Declarations as "Aggregate" is, subject to the above provisions involving "each Incident" or "each Occurrence", the total limit of the Company's liability under this policy for all Damages tinder this coverage. II. MEDICAL PAYMENTS The Company will pay, in addition to the applicable Limit of Liability, up to $$1,500 per person, to or for each person who sustains Bodily Injury caused by an Occurrence during the Policy Period: A. while on the premises owned by or rented to the Insured with the permission of the Insured, or B. while elsewhere if such Bodily Injury: 1. arises out of the premises owned by or rented to the Insured or a condition in the ways immediately adjoining; 2, is caused by the activities of the Insured; or 3. is caused by the activities of, or is sustained by, a residence employee while engaged in the employment of the Insured. the reasonable expense of necessary medical, surgical, ambulance, hospital, professional nursing and funeral services, all incurred within four (4) years from the date of Occurrence. 2 14CPLr2151 (Ed. 11/09) Liberty Internam ] Healthcare Professional Liability anderwritm. a. non-payment of premium when due, including payment due on a prior policy issued by the Company and due during the current Polity Period covering the same risks insured under the policy; b. any Insured has violated any law of this state or of the United States pursuant to a judgment by a court or administrative tribunal and such violation has as one of its elements an act that materially increases a risk insured against Corder the policy; c. discovery of fraud or material misrepresentation committed by any Insured or any Insured's representative in either obtaining this insurance or pursuing a claim under the policy; d. discovery of a wilful or grossly negligent act or omission or of a violation of state law or regulation governing safety standards committed by any Insured that materially increases a risk insured against under the policy; e. any Insured or any Insured's representative has failed to implement any reasonable loss control requirement, agreed to as a condition of this insurance, and such failure materially increases a risk insured against under the policy; f. discovery of a change any Insured has made in any activity or property of the commercial or industrial enterprise resulting in a material, added risk, a materially -increased risk or a materially -changed risk, unless the added, increased or changed risk is included in the policy; g. determination by the California Commissioner of Insurance that loss of or change to any of the Company's reinsurance covering all or part of the risk insured against would threaten the Company's solvency or financial integrity; or h, determination by the California Commissioner of Insurance that continuation of the policy's coverage would place the Company in violation of any law in California or New York or that continuation of coverage would jeopardize the Company's solvency. II. In addition, it is hereby agreed and understood that Paragraph 2. of Part VIII.E., CONDITIONS, of the above referenced policy is hereby deleted in its entirety and replaced with the following: 2. NONRENEWAL The Company will renew this policy unless written notice of the Company's intent not to renew, stating the specific reasons for nonrenewal, is mailed to the Named Insured not less than ninety (90) days but no more than one hundred twenty (120) days before the policy expires. `Nomenewal" shall include the failure of the Company to offer a renewal policy which provides types and limits of coverage substantially equivalent to those contained in the expiring policy. A copy of such notice shall also be sent to the Named Insured's producer, if any (provided that the Named Insured's producer is not an employee of the Company). ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. I_�I�11•I HCPLr2037-9000 CA (11/09) Liberty Ieaternati<rttai Healthcare Professional Liability Underwriters. LIBERTY INSURANCE UNDERWRITERS, INC. (A Stock Insurance Company, hereinafter the "Compann THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA AMENDATORY ENDORSEMENT I. In consideration of the premium paid, it is hereby agreed and understood that Paragraph 1. of Part VIII.E., CONDITIONS, of the above referenced policy is hereby deleted in its entirety and replaced with the following: 1. CANCELLATION This insurance may be canceled on the customary short -rate basis by the Named Insured at any time by written notice or by surrender of this policy to the Company or its authorized representative and the Company shall refund the paid premium less the earned portion thereof within thirty (30) days of the latter of the effective date of cancellation or the date of delivery of the Insured's notice of intent to cancel, subject always to the retention by the Company of any minimum premium stipulated herein (or proportion thereof previously agreed upon). The earned portion of the premium shall be computed on the customary short -rate basis unless any state law or regulation of the state shown in the mailing address of the Named Insured in the Declarations requires that return premium be computed on a pro -rata basis, even in the event of cancellation by the Named Insured. This insurance may also be canceled, by the Company or by its authorized representative on its behalf, by sending to the Named Insured, by first-class registered or certified mail, at the Named Insured's address last known to the Company or its authorized agent, not less than ninety (90) days written notice stating the specific reason for such cancellation and when the cancellation shall be effective. In such case, the Company shall refund the paid premium less the earned portion thereof within ten (10) business days after the effective date of cancellation, subject always to the retention by the Company of any minimum premium stipulated herein (or proportion thereof previously agreed upon) in the event of cancellation either by the Company or the Named Insured. In case of non-payment of premium, only thirty (30) days written notice of cancellation must be given by the Company. Minimum premium shall not apply to the return, of uneamed premium if cancellation is by the Company. A copy of such notice shall also be sent to the Named Insured's producer, if any (provided that the Named Insured's producer is not an employee of the Company). If the policy has been in effect for sixty (60) days or less, cancellation by the Company shall only be effective if based on one or more of the following reasons: a. non-payment of premium; b. this policy was obtained through material misrepresentation that was relied on by the Company, and such policy would not have been issued by the Company under the same terms and conditions if correct information had been disclosed; c. material failure to comply with any policy term, condition or contractual duty; d. the risk originally accepted ander this policy has measurably increased, or e. the Company's loss of the reinsurance that provided coverage for all or a substantial part of the risk insured wider this policy. If the policy has been in effect for more than sixty (60) days, cancellation by the Company shall only be effective if based on one or more of the following reasons: HCPI`2037-9000 CA (11/09) Pb-"L Internat#ana3 Healthcare Professional Liability under vritm. New York - It is agreed that the provisions of the "Nuclear Energy Liability Exclusion Endorsement -Board Form`" printed above, do not apply in New York with respect to any Non -Owned Auto Liability Coverage afforded by this policy. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. _3 HCPL-2038 (Ed. 11/09) laberty Internaticmal Healthcare Professional Liability qO unde>writ. (3) the Bodily Injury or Property Damage arises out of the furnishing by an Insured of services, materials, parts of equipment in connection with the planning, construction, maintenance, operation or use of any Nuclear Facility, but if such facility is located within the United States of America, its territories of possession or Canada, this exclusion (3) applies only to Property Damage to such Nuclear Facility and any property thereof. H. As used in this endorsement: "Hazardous Properties" include radioactive, toxic or explosive properties; "Nuclear Material" means Source Material, Special Nuclear Material or By-product Material; "Source Material" "Special Nuclear Material" and "By-product Material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof; "Spent Fuel" means any fuel element or fuel component, solid or liquid, which has been used or exposed to radiation in a Nuclear Reactor; "Waste" means any waste material: (a) containing By-product Material other than the tailings or Wastes produced by the extraction or concentration of uranium or thorium from any ore processed primary for its source material content, and (b) resulting from the operation by any person or organization of my Nuclear Facility included under the first two paragraphs of the definition of Nuclear Facility; "Nuclear Facility" means: (a) any Nuclear Reactor, (b) any equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing Spent Fuel, or (3) handling, processing or packaging Waste; (c) any equipment or device used for the processing, fabricating or alloying of Special Nuclear Material if at any time the total amount of such material in the custody of the Insured at the premises where such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; (d) any structure, basis, excavation, premises or place prepared or used for the storage of disposal of Waste, and includes the site on which any of the foregoing is located, all operations conducted on such site and all premises used for such operations; "Nuclear Reactor" means any apparatus designed or used to sustain nuclear fission in self-supporting chain reaction or to contains critical mass of fissionable material, "Property Damage" includes all forms of radioactive contamination of property. HCPLr2038 (Ed. 11/09) Liberty 10 Internatitxtai Healthcare Professional Liability underevriten. LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, haminaftea the "Company' ENDORSEMENT NO. [ Effective Date: 08/21/2014 Policy Number: AHY-754318001 Issued To: Felice Hernandez THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR ENERGY LIABILTIY EXCLUSION ENDORSEMENT BROAD FORM It is agreed that: The policy does not apply: A. Under any Liability Coverage, to Bodily Injury or Property Damage: (1) with respect to which an Insured under the policy is also an Insured under a Nuclear Energy Liability Policy issued by Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Liability Underwriters or Nuclear Insurance Association of Canada, or would be an Insured under any such policy but for its termination upon the exhaustion of its Limit of Liability; or (2) resulting from the Hazardous Properties of Nuclear Material and with respect to which (a) any person or organization is required to maintain financial protection pursuant to the Atomic Energy Act of 1954, or any law mandatory thereof, or (b) the Insured is, or had this policy not been issued would be entitled to indemnity from the United States of America or any agency thereof, under any agreement entered into by the United States of America, or any agency thereof, with any person or organization. B. Under any Medical Payments Coverage., or under any Supplementary Payments or Claims Expenses provision relating to first aid, to expenses incurred with respect Bodily Injury resulting from the Hazardous Properties of Nuclear Material and arising out of the operation of a Nuclear Facility by any person or organization. C. Under any Liability Coverage, to Bodily Injury or Property Damage resulting from the Hazardous Properties of Nuclear Material; if (1) the Nuclear Material: (a) is at any Nuclear Facility owned by, or operated by or operated on behalf of, any Insured or (b) has been discharged or dispersed therefrom; (2) the Nuclear Material is contained in Spent Fuel or Waste at any time possessed, handled, used, processed, stored, transported or disposed of by or on behalf of an Insured; or HCPL, 2038 (Ed. 11/09) Healthcare Professional Liability All premiums for this policy shall be computed in accordance with the Company's Hiles, rates, rating plans, premiums and minimum premiums applicable to the insurance afforded herein. Premium designated in this policy is a deposit premium only which shall be credited to the amount of the earned premium due at the end of the Policy Period. At the close of each period (or part thereof terminating with the end of the Policy Period) designated in the Declarations as the audit period the earned premium shall be computed for such period, and upon notice thereof to the Named Insured, shall become due and payable. If the total earned premium for the Policy Period is less than the premium previously paid, the Company shall return to the Named Insured the unearned portion paid by the Named Insured. The Named Insured shall maintain records of such information as is necessary for premium computation, and shall send copies of such records to the Company at the end of the Policy Period and at such times during the Policy Period as the Company may direct. L. INSPECTION AND AUDIT The Company shall be permitted but not obligated to inspect the Named Insured's property and operations at any time. Neither the Company's rights to make inspections, nor the making thereof, not any report thereon shall constitute an undertaking, on behalf of or for the benefit of the Named Insured or others, to determine or warrant that such property or operations are safe or healthful, or are in compliance with any law, rule or regulation. The Company may examine and audit the Named Insured's books and records at any time during the Policy Period and extensions thereof and within three years after the final temivuation of this policy as far as they relate to the subject matter of this insurance. IN WITNESS WHEREOF, the Company has caused this policy to be signed by its President and Secretary. 'L P..a..,_.' *( e, III President 14 I-ICPL-2037 (Ed. 11/09) Secretary Healthcare Professional Liability The Company will renew this policy unless written notice of the Company's intent not to renew, stating the specific reasons for nonrenewal, is mailed to the Named Insured not less than ninety (90) days before the policy expires. "Nonrenewal" shall include the failure of the Company to offer a renewal policy which provides types and limits of coverage substantially equivalent to those contained in the expiring policy. Any notice of cancellation or nonrenewal will be mailed by fust -class registered or certified mad to the Named Insured at the last mailing address known to the Company. Proof of mailing will be sufficient proof of notice. F. CHANGES The terms of this policy shall not be waived or changed, except by endorsement issued to form a part of this policy. G. DECLARATIONS By acceptance of this policy, the Insured agrees that the statements in the Declarations are the Insured's agreements and representations, that this policy is issued in reliance upon the truth of such representations and that this policy embodies all agreements existing between the Insured and the Company or any of its agents relating to this insurance. H. OTHER INSURANCE If there is other valid insurance (whether primary, excess, contingent or self-insurance) which may apply against a loss or claim covered by this policy, the insurance provided hereunder shall be deemed excess insurance over and above the applicable limit of all other insurance or self-insurance. When this insurance is excess, the Company shall have no duty under this policy to defend any claim or Suit that any other insurer or self -insurer has a duty to defend. If such other insurer or self -insurer refuses to defend such claim or Suit, the Company shall be entitled to the Insured's rights against all such other insurers or self -insurers for any Claims Expenses incurred by the Company. When both this insurance and other insurance or self-insurance apply to the loss on the same basis, whether primary, excess or contingent, the Company shall not be liable under this policy for a greater proportion of the loss or defense costs than the applicable Limit of Liability under this policy for such loss bears to the total applicable limit of liability of all valid and collectible insurance against such loss. Subject to the foregoing, if a loss occurs involving two or more policies, each of which provides that its insurance shall be excess, each will contribute pro -rata. I. REIMBURSEMENT While the Company has no duty to do so, if the Company pays Damages or Claims Expenses: a. within the amount of the applicable Deductible; b. in excess of the applicable Limit of Liability, all Insureds shall be jointly and severally liable to the Company for such amounts. Upon written demand, the Insured shall repay such amounts to the Company within thirty (30) days thereof. Failure to pay any amount indicated may lead to policy cancellation. J. SUBROGATION To the extent of any payment under this policy, the Company shall be subrogated to all the Insured's rights of recovery therefore against any person, organization or entity and the Insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Insured shall do nothing after any loss to prejudice such rights. K PREMIUM 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability The Insured and each of its employees shall cooperate with the Company and, upon the Company's request, assist in making settlements, in the conduct of Suits and enforcing any right of contribution or indemnity against any person or organization who may be liable to the Insured because of injury or Ramage with respect to which this insurance is afforded under this policy, and the Insured, and any of its members, partners, officers, directors, stockholders and employees that the Company deems necessary shall attend beatings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. The Insured shall not, except at the Insured's own cost, voluntarily make any payments, assume any obligations or incur any expense. D. BANKRUPTCY OR INSOLVENCY Bankruptcy or insolvency of the Insured or of the Insured's estate shall not relieve the Company of any of its obligations hereunder. E. CANCELLATION AND NONRENEWAL 1. CANCELLATION This insurance may be canceled on the customary short -rate basis by the Named Insured at any time by written notice or by surrender of this insurance to the Company or its authorized representative and the Company shall refund the paid premium less the earned portion thereof within thirty (30) days of the latter of the effective date of cancellation or the date of delivery of the Insured's notice of intent to cancel, subject always to the retention by the Company of any minimum premium stipulated herein (or proportion thereof previously agreed upon). The earned portion of the premium shall be computed on the customary short -rate basis unless any state law or regulation of the state shown in the mailing address of the Named Insured in the Declarations requires that return premium be computed on a pro -rata basis, even in the event of cancellation by the Named Insured. This insurance may also be canceled, with or without the return or tender of the unearned premium, by the Company or by its authorized representative on its behalf, by sending to the Named Insured, by first- class registered or testified mail, at the Named Insured's address last known to the Company or its authorized agent, not less than ninety (90) days written notice stating the specific reason for such cancellation and when the cancellation shall be effective. In such case, the Company shall refund the paid premium less the earned portion thereof within ten (10) business days after the effective date of cancellation, subject always to the retention by the Company of any minimum premium stipulated herein (or proportion thereof previously agreed upon) in the event of cancellation either by the Company or the Named Insured. In case of nonpayment of premium, only thirty (30) days written notice of cancellation must be given by the Company. Minimum premium shall not apply to the return of unearned premium if cancellation is by the Company. Cancellation by the Company shall only be effective if based on one or more of the following reasons: a. nonpayment of premium; b. the policy was obtained through material misrepresentation that was relied on by the Company, and such policy would not have been issued by the Company under the same terms and conditions if correct information had been disclosed; C. material failure to comply with any policy tern, condition or contractual duty; d. the risk originally accepted has measurably increased; or e. loss by the Company of reinsurance which provided coverage for all or a substantial part of the risk insured. 2. NONRENEWAL 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability A. physical injury to or destruction of tangible property which occurs during the Policy Period, including the loss of use thereof at any time resulting therefrom; or B. loss of use of tangible property which has not been physically injured or destroyed provided such loss of use is caused by an Occurrence during the Policy Period; or —� C. economic loss, whether or not resulting from physical injury or damage to person or property, except if such loss was caused, or alleged to have been caused, in whole or part, by anti-trust, breach of contract, price-fixing, restraint of trade or unfair business practices by any Insured; "Suit" includes lawsuit and/or arbitration proceedings to which the Insured is required to submit to or to which the Insured has submitted with the Company's consent; "Underground Property Damage Hazard" includes Underground Property Damage as defined herein and Property Damage to any other property at any time resulting therefrom. "Underground Property Damage" means Property Damage to wires, conduits, pipes, mains, sewers, tanks, tunnels, any similar property, and any apparatus in connection therewith, beneath the surface of the ground or water, caused by and occurring during the use of mechanical equipment for the purpose of grading land, paving, excavating, drilling, burrowing, filling, back- filling or pile driving. The Underground Property Damage Hazard does not include Property Damage: A. arising out of operations performed for the Named Insured by independent contractors; or B. included within the Completed Operations Hazard; or C. of which liability is assumed by the Insured under an Incidental Contract. VIII. CONDITIONS A. LEGAL ACTION AGAINST THE COMPANY A person or organization may bring Suit against the Company including, but not limited to, a Suit to recover on an agreed settlement or on a final judgement against an Insured; but the Company will not be liable for Damages that are not payable under the terms of this policy or that are in excess of the applicable limit of insurance. An agreed settlement means a settlement and release of liability signed by the Company, the Insured and the claimant or the claimant's legal representative. However, no action by an Insured shall lie against the Company unless there has been full compliance with all of the terns of this policy. B. ASSIGNMENT Assignment of interest under this policy shall not bind the Company and its consent is endorsed herein; if, however, the Named Insured shall die, such insurance as afforded by this policy shall apply (1) to the Named Insured's legal representative as the Named Insured, but only while acting within the scope of his/her duties as such, and (2) with respect to the property of the Named Insured, to the person having proper temporary custody thereof, as Insured, but only until the appointment and qualification of the legal representative. C. ASSISTANCE AND COOPERATION OF INSURED The Insured shall give written notice to the Company as soon as practicable of any claim made against the Insured or of any specific circumstances involving a particular person likely to result in a claim. The notice shall identify the Insured and contain reasonably obtainable information with respect to the time, place and circumstances of the injury, including the names and addresses of the injured and of available witnesses and the extent of the type of claim anticipated. If a claim is made or Suit is brought against the Insured, the Insured shall immediately forward to the Company every demand, notice, summons or other process received by the Insured or die Insured's representative. 14 HCPI-2037 (Ed. 11/09) Healthcare Professional Liability "Mobile Eq ipment" means a land vehicle (including any machinery or apparatus attached thereto), whether or not self-propelled: A. not subject to motor vehicle registration; or B. maintained for use exclusively on premises owned by or rented to the Named Insured, including the ways immediately adjoining; or C. designed for use principally off public roads; or D. designed or maintained for the sole purpose of affording mobility to equipment of the following types forming an integral part of or permanently attached to such vehicle: power crimes, shovels, loaders, diggers and drills; concrete mixers (other than the mix -in -transit type); graders, scrapers, rollers and other road construction or repair equipment, air -compressors, pumps and generators, including spraying, welding and building cleaning equipment; and geophysical exploration and well servicing equipment; "Named Insured" means the organization named in Item 1 of the Declarations of this policy. "Named Insured" also shall include any organization which is acquired or formed by the Named Insured and over which the Named Insured maintains ownership or majority interest, other than a joint venture, but this insurance shall not apply if such new organization is also an Insured under any other similar liability or indemnity policy or would be Insured tinder any such policy but for exhaustion of its limits of liability. Unless written notice is given to the Company, this coverage shall terminate ninety (90) days from the date any such organization is acquired or formed by the Named Insured, or the end of the Policy Period whichever is earlier, and shall only apply to claims brought against the Insured arising out of the business or professional occupation specified in the Declarations; "Named Insured's Products" means goods or products manufactured by the Named Insured or by others trading tinder the name of the Named Insured, including any container th rcoh,, "Occurrence" means an accident, including continuous or repeated exposure to substantially the same general conditions, which results in Bodily Injury or Property Damage, neither expected not intended from the standpoint of any Insured or Advertising Injury, "Personal Injury" means injury arising out of an offense committed during the Policy Period, if such injury result from: A. false arrest, detention or imprisonment, or malicious prosecution; or B. the publication or utterance of a libel or slander or of other defamatory or disparaging material, or a publication or utterance in violation of an individual's right of privacy; except publications or utterances in the course of or related to advertising, broadcasting or telecasting activities conducted by or on behalf of the Named Insured; or C. wrongful entry or eviction, or other invasion of the right of private occupancy; Any such act, described in A, B or C above, together with all related acts described in A, B or C above shall be considered one Personal Injury and be subject to the same Limit of Liability. "Policy Period" means, whenever used in this policy, the period from the inception date of this policy to the policy expiration date as set forth in the Declarations or its earlier termination date, if any; "Products Hazard" includes Bodily Injury and Property Damage arising out of the Named Insured's Products or reliance upon a representation or warranty made at any time with respect thereto, but only if the Bodily Injury or Property Damage occurs away from the premises owned by or rented to the Named Insured and after physical possession of such products has been relinquished to others. Equipment specifically designed, made or altered by the Insured for a patient or client in the performance of the Insured's profession or operation of business, shall not be included in the "Products Hazard!',- "Property azard"; "Property Damage" means: 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability C. when the portion of the work of which the Bodily Injury or Property Damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as part of the same project. Operations which may require further service, maintenance work, correction, repair or replacement because of any defect or deficiency, but which are otherwise complete, shall be deemed completed. The Completed Operations Hazard does not include Bodily Injury or Property Damage arising out of: A, operations in connection with the transportation of property, unless the Bodily Injury or Property Damage arises out of a condition in or on a vehicle created by the loading or unloading thereof, or B. the existence of tools, installed equipment or abandoned or caused material, or C. operations for which the classification stated in the policy or in the Company's manual specifies "including completed operations'; "Damages" means compensatory judgments, settlements or awards but does not include punitive or exemplary Damages, fines or penalties, the return of fees or other consideration paid to the Insured, or the portion of any award or judgment caused by the multiplication of actual Damages under federal or state law. However, if a Suit is brought against the Insured with respect to a claim for alleged acts or omissions falling within the scope of coverage afforded by this insurance seeking both compensatory and punitive or exemplary Damages, then the Company will afford a defense to such action, without liability however, for payment of such punitive or exemplary Damages; "Explosion Hazard" includes Property Damage arising out of blasting or explosion. The Explosion Hazard does not include Property Damage: A. arising out of the explosion of air or steam vessels, piping under pressure, prime movers, machinery or power transmitting equipment, or B. arising out of operations performed for the Named Insured by independent contractors; or C. included within the Completed Operations Hazard or the Underground Property Damage Hazard; or D. for which liability is assumed by the Insured under an Incidental Contract; "Hostile Fire" means one which becomes uncontrollable or breaks out from where it was intended to be; "Incident" means any act or omission: A. in the rendering of or failure to render services by the Insured, or by any person for whom the Insured is legally responsible; including but not limited to services as a Good Samaritan or case management or utilization review services; or B. in the performance of services by the Insured as a member of a formal accreditation, ethics, peer review, licensing board, standards review or similar professional boardor committee of a professional organization; in the conduct of the business or professional occupation specified in the Declarations. Any such act or omission together with all related acts or omissions shall be considered one Incident and be subject to the same Limit of Liability; "Incidental Contract" means any oral or written contract or agreement relating to the operation of the Named Insured's business, except as respects Fire Legal Liability; "Insured" means any person or organization qualifying as an Insured in Section II, PERSONS INSURED. The insurance afforded applies separately to each Insured against whom claim is made or Suit is brought, except with respect to the Company's "Each Incident" or "Each Occurrence" Limit of Liability, but this provision does not expand or alter the coverage under this policy; 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability "Advertising Injtuy" means injury arising out of an offense committed during the Policy Period occurring in the course of the Named Insured's advertising activities, if such injury arises out of libel, slander, defamation, violation or right of privacy, piracy, or infringement of copyright, title or slogan; "Assault" means any willful attempt or threat to inflict injury upon the person of another, when coupled with an apparent present ability to do so, and any intentional display of force such as would give the victim reason to fear or expect immediate bodily harm; "Automobile" means any land motor vehicle, tractor, trailer or semi -trailer designed for travel on public roads (including any machinery or apparatus attached thereto), but does not include Mobile Eq ipment; "Bodily Injury" means bodily injury, sickness or disease, mental anguish, psychological injury or emotional distress sustained by any person which occurs during the Policy Period including death at any time resulting therefrom; "Claims Expenses" means: A. fees charged by an attorney(s) and/or independent adjustor(s) designated by the Company and all other fees, costs and expenses resulting from the investigation, adjustment, defense and appeal of a claim, Suit or proceedings arising in connection therewith, if incurred by the Company, or by the Insured with written consent of the Company, but does not include salary charges or expenses of regular employees or officials of the Company; B. all costs taxed against the Insured in such Suits and all interest on the entire amount of any judgment therein which accrues after entry of the judgement and before the Company has paid, tendered or deposited, whether in court or otherwise, the part of the judgement which does not exceed the limit of the Company's liability; C. premiums on appeal bonds and premiums on bonds to release attachments in such Suits, but not for bond amounts in excess of the applicable Limit of Liability of this policy, but the Company shall have no obligation to apply for or furnish any such bond; "Collapse Hazard" includes "Structural Property Damage" as defined herein and Property Damage to any other property at any time resulting therefrom. "Structural Property Damage" means the collapse of or structural injury to any building or structure due to: A. grading of land, excavating, burrowing, filling, back -filling, tunneling, pile driving, cofferdam work or caisson work; or B. moving, shoring, underpinning, razing or demolition of any building or structure or removal or rebuilding of any structural support thereof. The Collapse Hazard does not include Property Damage: A. arising out of operations performed for the Named Insured by independent contractors; or B. included within the Completed Operations Hazard or the Underground Property Damage Hazard; or C. for which liability is assumed by the Insured tinder an Incidental Contract; "Completed Operations Hazard" includes Bodily Injury and Property Damage arising out of operations or reliance upon a representation or warranty made at any time with respect thereto, but only if the Bodily Injury or Property Damage occurs after such operations have been completed or abandoned and occurs away from premises owned by or rented to the Named Insured. "Operations" includes materials, parts or equipment furnished in connection therewith. Operations shall be deemed completed at the earliest of the following tines: A. when all operations to be performed by or on behalf of the Named Insured under the contract have been completed; or B. when all operations to be performed by or on behalf of the Named Insured at the site of the operations have been completed; or 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability which the Insured practices or conducts business or is otherwise qualified to practice the Named Insured's business or professional occupation in the absence of such law; 25. to claims based on or arising out of services provided by any Insured, to the extent such services are not authorized or permitted by the laws of the state(s) in which such Insured practices or conducts business; �- 26, to any claims based on or arising out of any act or omission by an Insured with respect to hiring, termination, harassment, compensation, or the tenure, term, condition, benefits or privilege of employment of any such person; 27. to any claims made or Suits brought against any Insured alleging in whole or part; a. physical assault, abuse, molestation, or habitual neglect, or licentious, immoral, amoral or other behavior that was committed or alleged to have been committed, by the Insured or by any person for whom the Insured is legally responsible; and/or b. sexual assault, abuse, or molestation, or licentious, immoral, amoral or other behavior which was threatened, intended to, lead to or culminated in, any sexual act whether committed intentionally, negligently, inadvertently or with the belief, erroneous or otherwise, that the other party is consenting and has the legal and mental capacity to consent thereto, that was committed, or alleged to have been committed by the Insured or by any person for whom the Insured is legally responsible. This exclusion applies regardless of the legal theory or basis upon which the Insured is alleged to be legally liable or responsible in whole or in part, for any Damages arising out of sexual and/or physical abase, including but not limited to assertions of improper or negligent hiring, employment or supervision, failure to protect or warn the other party, failure to prevent the sexual abuse and/or physical abuse, failure to prevent assault and battery, failure to discharge the employee. However, notwithstanding the foregoing exclusion, the Insured shall be entitled to a defense as provided under the terms of the policy as to any claim upon which Suit is brought for any such alleged behavior, unless a judgment or final adjudication adverse to any Insured or an admission by any Insured, shall establish that such behavior caused, in whole or part, the injury claimed in such claim or Suit. The Company shall not be required to appeal a judgment or final adjudication adverse to the Insured. This duty to defend will not apply to claims brought alleging conduct specified in Exclusion 26, above; 28. to Bodily Injury and Property Damage included within the Products Hazard or Completed Operations Hazard, 29. to Personal Injury or Advertising Injury arising out of: a. the willful violation of a penal statute or ordinance committed by or with the knowledge or consent of the Insured; b. a publication or utterance of a libel or slander, or a publication or utterance in violation of an individual's right of privacy if the first injurious publication or utterance of the same or similar material by or on behalf of the Named Insured was made prior to the effective date of this insurance; c. libel or slander or the publication or utterance of defamatory or disparaging material concerning any person or organization or goods, products or services, or in violation of an individual's right of privacy, made by or at the direction of the Insured with knowledge of falsity thereof; 30, to any claim brought by, or on behalf of, any Insured under this policy against any other Insured under this policy, except if such claim results from services rendered in a patient or client relationship; \SII. DEFINITIONS When used in this policy (including endorsements forming a part hereof): 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability b. any other Automobile or aircraft operated by any person in the course of his or her employment by any Insured; but this exclusion does not apply to the parking of an Automobile on premises owned by, rented to or controlled by the Named Insured or the ways immediately adjoining, if such Automobile is not owned by or rented or loaned to any Insured; 15. to Bodily Injury or Property Damage arising out of: a. the ownership, maintenance, operation, use, loading or unloading of any Mobile Eq ipment while being used in any prearranged or organized racing, speed or demolition contest or in any stunting activity or in practice or preparation for any such contest or activity; or b. the operation or use of any snowmobile or trailer designed for use therewith, 16. to Bodily Injury or Property Damage arising out of and in the course of the transportation of Mobile Eq ipment by an Automobile owned or operated by or rented or loaned to any Insured; 17. to Property Damage to: a. property owned, rented or occupied by, the Named Insured; or b. personal property in the care, custody or control of the Insured; 18. to Property Damage to premises alienated by the Named Insured arising out of such premises or any part thereof; 19. to loss of use of tangible property which has not been physically injured or destroyed resulting from: a. a delay in or lack of performance by or on behalf of the Named Insured or any contract or agreement; or b. the failure of the Named Insured's Products or work performed by or on behalf of the Named Insured to meet with the level of performance, quality, fitness or durability warranted or represented by the Named Insured; but this exclusion does not apply to loss of use of other tangible property resulting from the sudden and accidental physical injury to or destruction of the Named Insured's Product or work performed by or on behalf of the Named Insured after such products or work have been put to use by any person or organization other than an Insured; 20. to Property Damage to the Named Insured's Products arising out of the use of such products or any part of such products; 21. to claims brought for the withdrawal, inspection, repair, replacement, or loss of use of the Named Insured's Products or work completed by or for the Named Insured or any property of which such products or work form a part, if such products, work or property are withdrawn from the market or from use because of any known or suspected defect or deficiency therein; 22. to claims brought against any Insured as a proprietor, owner, partner, manager, superintendent, or officer of any hospital, sanitarium, medical clinic, health maintenance organization, managed care facility, foster care agency, adoption agency or any other facility not specified in the Declarations or any endorsement thereto; 23. to claims arising out of the services performed by any Insured as a physician, surgeon, dentist, nurse midwife, chiropractor, podiatrist, osteopath, psychiatrist, cytotechnologist, or perfusionist, except for services performed as an optometric physician, or to claims brought against the Insured arising out of any trade, business, employment, profession or occupation other thanas specified in the Declarations or any endorsement thereto; 24. to claims based on or arising out of the practice of the Named Insured's business or professional occupation as stated in the Declarations unless the Insured is properly licensed or certified by the laws of the state(s) in 14] HCPL-2037 (Ed. 11/09) Healthcare Professional Liability from the Insured's activities or the activities of others and whether or not such is sudden, gradual, accidental, intended, foreseeable, expected, fortuitous or inevitable and wherever or however such occurs. But this exclusion shall not apply to Bodily Injury or Property Damage caused by heat, smoke or fumes from a Hostile Fire unless such fire involves: a. materials which are or were at any time used for the handling, storage, disposal, processing or treatment of waste; or b. any premises, site or location: L which is or was at any time used for handling, storage, disposal, processing or treatment of waste; or ii. on which any Insured or contractors or subcontractors working directly or indirectly on any Insured's behalf are performing operations to test for, monitor, cleanup, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, pollutants; 7. to Bodily Injury or Property Damage due to war, whether or not declared, civil war, insurrection, rebellion or revolution or to any act or condition Incident to any of the foregoing; 8. to Bodily Injury or Property Damage for which the Insured or the Insured's indemnitee may be liable: a. as a person or organization engaged in the business of manufacturing, distributing, selling or serving alcoholic beverages; or b. if not so engaged, as an owner or lessor of premises used for such purposes, if such liability is imposed by, or because of, the violation of any statute, ordinance or regulation pertaining to the sale, gift, distribution or use of any alcoholic beverage, including the selling, serving or giving of any alcoholic beverage to a minor, 9. to Property Damage included within: a, the Explosion Hazard; b. the Collapse Hazard; C. the Underground Property Damage Hazard, 10. to any dishonest, fraudulent, criminal or malicious actor omission of any Insured; 11. to any claim made by an employer against an Insured if the Insured is a salaried employee of such employer; 12. to acts or omissions by any Insured expected or intended to cause Bodily Injury or Property Damage regardless or whether or not such act or omission was intended to cause the specific Bodily Injury or Property Damage sustained. This exclusion shall not apply to any intentional act by or at the direction of the Insured which results in Bodily Injury, if such Bodily Injury arises solely from the use of reasonable force for the purpose of protecting persons or property; 13. to liability assumed by any Insured under any contract or agreement except to the extent: a. such Insured would be liable in the absence of such contract or agreement, including liability assumed by any Insured under a contract or agreement with a Health Maintenance Organization, Preferred Provider Organization, Independent Practice Association, or any other similar organization; b. the contract or agreement is an Incidental Contract and COVERAGE B, GENERAL. LIABILITY COVERAGE has been purchased; 14. to Bodily Injury or Property Damage arising out of the ownership, maintenance, operation, use, loading or unloading of: a. any Automobile or aircraft owned or operated by or rented or loaned to any Insured, or 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability E. FIRST AID REIMBURSEMENT Up to j$2,500, for all medical related expenses for which the Insured has voluntarily made payment or incurred, for fust aid rendered to others as a result of any Bodily Injury done to another, covered by this policy, which happens during the Policy Period. ��— This provision does not apply to Bodily Injury to any person as defined as an Insured in this policy. The first aid must be provided within a 48-hour period after the injury happens. Nq. EXCLUSIONS This insurance does not apply: 1. with respect to Advertising Injury: a. to any Insured in the business of advertising, broadcasting, publishing or telecasting, or b. to any injury arising out of any act committed by any Insured with actual malice; 2. to Advertising Injury arising out of: a. failure of performance of contract, but this exclusion does not apply to the unauthorized appropriation of ideas based upon alleged breach of implied contract; or b. infringement of trademark, service mark or trade name, other than titles or slogans, by use thereof on or in connection with goods, products or services sold, offered for sale or advertised; or c. incorrect description or mistake in advertised price of goods, products or services sold, offered for sale or advertised; 3. to any obligation for which the Insured, or any carrier as his/her insurer, may be held liable under any workers' compensation, unemployment compensation or disability benefits law, or under any similar law; 4. to Bodily Injury or Personal Injury to any employee of the Insured arising out of and in the course of his/her employment by the Insured or to any obligation of the Insured to indemnify another because of Damages arising out of such injury; 5. to Bodily Injury or Property Damage arising out of the ownership, maintenance, operation, use, loading or unloading of: a. any watercraft owned or operated by or rented or loaned to any Insured; or b. any other watercraft operated by any person in the course of his/her employment by any Insured. This exclusion does not apply to any watercraft under 26 feet in length provided such watercraft is neither owned by the Named Insured nor being used to carry persons or property for a charge. Irrespective of this coverage, where the Insured is covered or protected by other insurance against any loss or claim which would otherwise have been paid by the Company under this policy there shall be no contribution or participation by this Company on the basis of excess, contributing, deficiency, concurrent, or double insurance or otherwise; 6. to any claim, action, judgement, liability, settlement, loss, defense, cost or expense in anyway arising out of actual, alleged or threatened pollution, contamination or any environmental impairment resulting from seepage, discharge, dispersal, release or escape of any solid, liquid, gaseous or radioactive matter including, but not limited to, smoke, vapors, soots, fumes, acids, alkalis, chemicals or toxic matter, or waste material (including materials to be recycled, reconditioned or reclaimed); or. oil or other petroleum substances or derivatives (including oil refuse or oil mixed with waste), or thermal or vibratory effect including, but not limited to, sound or noise, heat or cold, into or upon land, the atmosphere or any water course or body of water, underground water or water table supplies, whether such results directly, indirectly or in concurrence or in any sequence 14 I-ICPIr2037 (Ed. 11/09) Healthcare Professional Liability V. SUPPLEMENTARY PAYMENTS The Company will pay, in addition to the applicable Limit of Liability: A. FIRST PARTY ASSAULT Up to $5,000, for: 1, medical expenses incurred as a result of Bodily Injury to the Insured; and 2. repair or replacement of personal property owned by the Insured, caused by any one Assault by, or at the direction of, a person other than an Insured during the Policy Period, which happens on the Insured's workplace premises, including the ways immediately adjoining such workplace premises, while away from such workplace premises while conducting an authorized work activity, or while traveling to or from such workplace premises. Subject to the foregoing, the total amounts payable under this extension shall not exceed $10,000 for all Assaults which happen during the Policy Period. This coverage does not apply to damage to any mode of transportation used by the Insured to go to and from the Insured's workplace premises, or damage to any business or personal property owned, leased or rented by any other person or business enterprise while in the Insured's possession. This coverage applies as excess over any other available insurance covering such loss; B. LICENSING BOARD REIMBURSEMENT Up to $5,000 for attorney fees, and other costs, expenses or fees resulting from the investigation or defense of all proceedings before an entity responsible for regulating the Insured's professional conduct, arising out of an Incident, insured as a result of notice or notices of proceedings first received by the Insured during the Policy Period. This payment, however, does not apply to any expenses or fees resulting from criminal proceedings. All such proceedings arising out of the same or related Incident shall be 1. considered first made during the Policy Period in which the earliest complaint arising out of such same or related Incident was made; and 2. subject to a single limit as stated above. Subject to the foregoing, the total amounts payable under this extension shall not exceed $10,000 for all Incidents of which notice or notices are first received by all Insureds during the Policy Period, C. WAGE LOSS AND EKTENSE For lost wages, costs and expenses, caused by the Insured's attendance at the Company's request at any trial(s), hearing(s) or arbitration proceeding(s) involving a civil Suit(s) against such Insured for covered Damages. Regardless of the number of Insureds, trials, hearings or arbitration proceedings, the amount so payable for any one series of trials, hearings or arbitration proceedings arising out of the same Incident and/or Occurrence shall not exceed $10,000. D. DEPOSITION EXPENSE Up to $5,000, for all reasonable fees, costs and expenses necessary to represent the Insured at all depositions, which the Insured is required to attend., arising out of the profession indicated in the Declarations, of which notice or notices of required attendance are first received by the Insured during the Policy Period, but this payment does not apply to any deposition where the Insured is acting as a paid expert 14 HCPL-2037 (Ed. 11/09) Healthcare Professional Liability Insured refuses to consent to any settlement recommended in writing by the Company and elects to contest the claim or continue any legal proceedings in connection with such claim, then the Company shall be relieved of any further duty to defend the claim, and the liability of the Company for Damages and Claims Expenses shall not exceed the amount for which the claim could have been settled as well as the Claims Expenses incurred by the Company or with the Company's consent up to the date of such refusal. The Insured shall not admit liability, not assume any obligations, incur any costs, charges, or expenses or enter into any settlement without the Company's written consent. II. PERSONS INSURED Each of the following is an Ynsured under this policy to the extent set forth below: A. If the Named Insured is an individual, the Named Insured so designated in the Declarations; B. If the Named Insured is a sole proprietorship, the Named Insured so designated in the Declarations; C. If the Named Insured is a partnership, the partnership so designated in the Declarations and any partner thereof; D. If the Named Insured is other than an individual, sole proprietorship or partnership, the organization so designated in the Declarations, and any owner, officer, director, principal, trustee or stockholder thereof; E. Any employee of the Named Insured, but only while such employee was acting on behalf of the Named Insured and within the scope of the employee's duties as such or for acts performed by such employee as a Good Samaritan or unpaid volunteer during the employee's term of employment with the Named Insured; F. Any volunteer, but solely while such person was acting within the scope of the volunteer's duties for, and on behalf of, the Named Insured; G. Any professional serving as a temporary replacement or substitute for an Insured, but solely while such person was acting within their duties for, and on behalf of, the Named Insured. During the term of such replacement, the person who is replaced by, or substituted for, shall not be an Insured under this policy, as respects COVERAGES A. and B. III. LlliffTS OF LIABILITY Regardless of the number of Coverage Parts that apply, the number of Insureds under this insurance, the number of persons and/or organizations who sustain Bodily Injury, Property Damage, Personal Injury and/or Advertising Injury, or the number of claims made or Suits brought, the Company's liability is limited as follows: A. The Limit of Liability stated in the Declarations as applicable to "each Incident" or "each Occurrence" is the total limit of the Company's liability for all Damages for "each Incident" and/or "each Occurrence" covered by the policy. All claims arising from the same or related Incident, Occurrence and/or Personal Injury shall be considered a single claim for the purpose of this insurance and shall be subject to the same Lunit of Liability. B. The Limit of Liability stated in the Declarations as "Aggregate" is, subject to the above provisions involving "each Incident" and/or "each Occurrence," the total limit of the Company's liability under this policy for all Damages. However, the Limit of Liability stated in the Declarations as "Aggregate" shall apply separately to any individual defined as an Insured under Section II, PERSONS INSURED, Subsections A, B, C or E, or any organization defined as an Insured under Subsection D. IV, POLICYTERRITORY This insurance applies to Bodily Injury, Property Damage, Personal Injury, or Advertising Injury which occurs anywhere in the world, provided that claim is made or Suit is brought within the United States of America, its territories or possessions, or Canada. 14 HCPI-2037 (Ed. 11/09) Liberty It, Intermi6onal Healthcare Professional Liability Urtcler vrlterta. (A Stock Imet ue Compmy, hem'aaifrer the "Company' i MEDICAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY THIS IS AN OCCURRENCE POLICY. PLEASE REVIEW THE POLICY CAREFULLY. The Company agrees with the Named Insured, in consideration of the payment of the premium, and in reliance upon the statements in the Declarations and in the. Application and subject to the Limit of Liability, exclusions, conditions and other terms of this policy, as follows: COVERAGES A. COVERAGE A, PROFESSIONAL LLABHXrY CO\TRAGE If indicated by a specific premium in the Declarations, the Company will pay on behalf of the Insured all sums which the Insured shall become legally obligated to pay as Damages because of Bodily Injury or Property Damage caused by an Incident or Personal Injury, to which this insurance applies in the operation of the business or conduct of the profession of the Named Insured as specified in the Declarations; which occurs during the Policy Period, B. COVERAGE B, GENERAL LIABILITY COVERAGE If indicated by a specific premium in the Declarations, the Company will pay on behalf of the Insured all sums which the Insured shall become legally obligated to pay as Damages because of Bodily Injury, Property Damage or Advertising Injury to which this insurance applies in die operation of the business or conduct of the profession of the Named Insured as specified in the Declarations, caused by an Occurrence during the Policy Period. This coverage specifically includes the following extensions: L Contractual Liability: Bodily Injury or Property Damage resulting from any Incidental Contract relating to the operation of the Named Insured's business, except if such injury or damage occurred prior to the execution of the Incidental Contract; 2. Host Liquor Liability: Bodily Injury or Property Damage arising out of the giving or serving of alcoholic beverages at functions incidental to the Named Insured's business; 3. Fire Legal Liability: Property Damage to structures or portions thereof rented to or leased to the Named. Insured, including fixtures permanently attached thereto, if such Property Damage arises out of fire. Solely as respects Fire Legal Liability coverage, all of the exclusions of the policy, other than Exclusions 6, 12 and 13 and the Nuclear Energy Liability Exclusion (Broad Form) are deleted; As respects coverage(s) provided by this insurance, the Company shall have the right and duty to defend any Suit against the Insured seeking Damages on account of such Bodily Injury, Pmperty Damage, Personal Injury or Advertising Injury, even if any of the allegations of the Suit are groundless, false or fraudulent, but the Company shall not be obligated to pay any claim or judgment or continue to defend any Suit after the applicable limit of the Company's liability has been exhausted by payment of Damages. The Company, at its option, shall select and assign defense counsel; however, the Named Insured may engage additional counsel, solely at their expense, to associate in the defense of any claim covered hereunder. Claims Expenses incurred by the Company shall be paid in addition to the applicable Limits of Liability. The Company shall also have the right to investigate any claim and/or negotiate the settlement thereof, as it deems expedient, but the Company shall not commit to any settlement without the Named Insured's written consent. If the Named 14 IICPL-2037 (Ed. 11/09) 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 POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. State specific policy forms and endorsements are not Included in the list below. Should you require descriptions or samples of these documents, please visit us online at www.hpso.com/policyforms. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. All products and services may not be available in all states and may be subject to change without notice. Think Green — expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms. COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G -121500-D Common Policy Conditions G -121501 -Cl Occurrence Policy Form - California G -121503-C Workplace Liability Form CNA82011 Healthcare Providers Related Claims Endorsement G-1 45184-A Policyholder Notice - OFAC Compliance Notice G -147292-A Policyholder Notice - Silica Mold & Asbestos Disclosure CNA81753 Cap on Losses from Certified Acts of Terrorism CNA81758 Offer of Terrorism Coverage - Disclosure of Premium GSL13424 Services to Animals GSL15563 Information Privacy Coverage Endorsement HIPAA Fines Penalties & Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement CNA80051 Amended Definition of Personal Injury Endorsement G -123846-D04 California Cancellation and Non -Renewal CNA79575 Exclusion of Cosmetic Procedures PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner's status change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Healthcare Providers Service Organization for details. Form #: G -141241-B Master Policy #: 188711433 H10412 Named Insured: Felice R Hernandez Policy #: 0619799393-8 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: POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. Think Green —expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G -121500-D Common Policy Conditions G -121503-C Workplace Liability Form G -121501-C1 Occurrence Policy Form - California G -145184-A Policyholder Notice - OFAC Compliance Notice G -147292-A Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 Sexual Misconduct Sublinnits of Liability Professional Liability & Sexual Misconduct Exclusion GSL1 5565 Healthcare Providers Professional Liability Assault Coverage GSL1 7101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL1 3424 Services to Animals CNA80051 Amended Definition of Personal Injury Endorsement CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G -123846-D04 California Cancellation and Non -Renewal CNA81753 Coverage & Cap on Losses from Certified Acts Terrorism CNA81758 Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA82011 Related Claims Endorsement CNA79575 Exclusion of Cosmetic Procedures PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ' residents: The PLICA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and/or county level, For WV residents: The surcharge, shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL insurance Guaranty Association - 2012 Regular Assessment, Fo,rrn#: G-1 41241 -B (03/2010) Named insured- Felice R Hernandez Master Policy* 188711433 Policy#: 0619799393