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• <br /> POLICY FORMS&ENDORSEMENTS <br /> The following are the policy forms and endorsements that apply to your current professional liability insurance policy. <br /> COMMON POLICY FORMS&ENDORSEMENTS <br /> FORM# DESCRIPTION <br /> G-121500-0 Common Policy Conditions <br /> G-121501-C Occurrence Policy Form <br /> 0-121503-C Workplace Liability Form <br /> CNA82011 Healthcare Providers Related Claims Endorsement <br /> G-145184-A Policyholder Notice-OFAC Compliance Notice <br /> 0-147292-A Policyholder Notice-Silica Mold&Asbestos Disclosure <br /> CNA81753 Cap on Losses from Certified Acts of Terrorism <br /> CNA81758 Offer of Terrorism Coverage-Disclosure of Premium <br /> GSL13424 Services to Animals <br /> GSL15563 Information Privacy Coverage Endorsement HIPAA Fines Penalties&Notification Costs <br /> GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability&Sexual Misconduct Exclusion <br /> GSL15565 Healthcare Providers Professional Liability Assault Coverage <br /> GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br /> CNAB0052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br /> CNA80051 Amended Definition of Personal Injury Endorsement <br /> 0-123846-C46 Washington Cancellation and Non-Renewal <br /> G-123854-046 Washington Amendatory Change Endorsement <br /> G-123811-046 Washington Amendatory Change Endorsement <br /> CNA79575 Exclusion of Cosmetic Procedures <br /> Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner's status <br /> change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Nurses <br /> Service Organization for details. <br /> Form#:G-141241-B Named Insured:Jean E Bergo <br /> Master Policy#:188711433 Policy#:0264753151-0 <br /> N10412 1 <br />