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DocuSign Envelope ID: 2AC19FOC- 9E3C- 4689- A96A- CCF2OD2FFB98 <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 # <br />DESCRIPTION <br />G-121500 -D <br />Common Policy Conditions <br />GSL10546NC <br />North Carolina Amendatory Endorsement <br />G- 121503 -C <br />Workplace Liability Form <br />G- 121501 -C <br />Occurrence Policy Form <br />G- 145184 -A <br />Policyholder Notice - OFAC Compliance Notice <br />G- 147292 -A <br />Policyholder Notice - Silica, Mold & Asbestos Disclosure <br />GSL15563 <br />Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs <br />GSL15564 <br />Sexual Misconduct Sublimity of Liability Professional Liability & Sexual Misconduct Exclusion <br />GSL15565 <br />Healthcare Providers Professional Liability Assault Coverage <br />GSL17101 <br />Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br />GSL13424 <br />Services to Animals <br />CNA80051 <br />Amended Definition of Personal Injury Endorsement <br />CNA80052 <br />Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />G- 123846 -C32 <br />North Carolina Cancellation and Non- Renewal <br />CNA81753 <br />Coverage & Cap on Losses from Certified Acts Terrorism <br />CNA81758 <br />Notice - Offer of Terrorism Coverage & Disclosure of Premium <br />CNA82011 <br />Related Claims Endorsement <br />CNA89027 <br />Entity Exclusion Endorsement <br />CNA89026 <br />Media Expense Coverage <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 -13 (0312010) Named Insured: Katrice A Hester <br />Master Policy#: 188711433 Policy#: 0647224005 <br />