2012-153 Aging - Linda Cole, RN - Laserfiche WebLink

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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.nso.com/policyforms COMMON POLICY FORMS&ENDORSEMENTS FORM# DESCRIPTION G-121500-D Common Policy Conditions GSL10546NC North Carolina Amendatory Endorsement G-121503-C Workplace Liability Form G-121501-C Occurrence Policy Form 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 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 GSL13424 Services to Animals G-123846-C32 North Carolina Cancellation and Non-Renewal GSL3886 Coverage &Cap on Losses from Certified Acts Terrorism GSL3908 Notice-Offer of Terrorism Coverage&Disclosure of Premium GSL19904 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 PLIGA 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 i Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. 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. Form#:G-1 41241-B(03/2010) Named Insured:Linda D Cole Master Policy#:188711433 Policy#:0423623038 I ;