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DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 <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-D Common Policy Conditions <br /> GSL10546NC North Carolina Amendatory Endorsement <br /> 0-121503-C Workplace Liability Form <br /> G-121501-C Occurrence Policy Form <br /> 0-145184-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 /> CNA80051 Amended Definition of Personal Injury Endorsement <br /> CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br /> G-123846-C32 North Carolina Cancellation and Non-Renewal <br /> CNA81753 Coverage&Cap on Losses from Certified Acts Terrorism <br /> CNA81758 Notice-Offer of Terrorism Coverage&Disclosure of Premium <br /> CNA82011 Related Claims Endorsement <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 FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association <br /> -2012 Regular Assessment. <br /> Form#:G-141241-B(03/2010) Named Insured:Janice Galloway <br /> Master Policy#:188711433 Policy#: 0312115639 <br />