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DocuSign Envelope ID: FCE3F262-3C43-41 138-130137-AE5E968413477 <br /> POLICY FORMS & ENDORSEMENTS <br /> The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your <br /> professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms& <br /> endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be <br /> available in all states. All products and services are subject to change without notice. <br /> Think Green —expanded definitions and copies of these policy forms and endorsements are available online at <br /> www,nso.com/policyforms <br /> COMMON POLICY FORMS& ENDORSEMENTS <br /> FORM # DESCRIPTION <br /> G-121500-D Common Policy Conditions <br /> GSL10546NC North Carolina Amendatory Endorsement <br /> G-121501-C Occurrence Policy Form <br /> G-1 45184-A Policyholder Notice-OFAC Compliance Notice <br /> G-147292-A Policyholder Notice- Silica, Mold &Asbestos Disclosure <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 /> GSL13424 Services to Animals <br /> GSL13425 Business Owner Coverage Extension Endorsement <br /> G-123846-C32 North Carolina Cancellation and Non-Renewal <br /> GSL3886 Coverage &Cap on Losses from Certified Acts Terrorism <br /> GSL3908 Notice-Offer of Terrorism Coverage & Disclosure of Premium <br /> GSL19904 Exclusion of Cosmetic Procedures <br /> OPTIONAL ENDORSEMENTS <br /> FORM# DESCRIPTION <br /> G-121504-C General Liability Form <br /> PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC <br /> TO YOUR STATE AND YOUR POLICY PERIOD. <br /> For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property& Liability Insurance <br /> Guaranty Association. <br /> For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement <br /> Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which <br /> includes charges at a municipality and/or county level. <br /> For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. <br /> For FL residents: The FICA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association <br /> -2012 Regular Assessment. <br /> Form#:G-141241-B(0312010) Named Insured:Vantage Care &Staffin <br /> Master Policy#:188711433 Policy#: 0597268785 <br />