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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 />G-121501-C Occurrence Policy Form <br />G-121503-C Workplace Liability Form <br />CNA82011 Healthcare Providers Related Claims Endorsement <br />G-145184-A Policyholder Notice - OFAC Compliance Notice <br />G-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 />CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />CNA80051 Amended Definition of Personal Injury Endorsement <br />G-123846-C32 North Carolina Cancellation and Non-Renewal <br />GSL10546NC North Carolina Amendatory Endorsement <br />CNA89026 Media Expense Coverage <br />CNA89026 Media Expense Coverage <br />CNA89027 Exclusion of Entity, Employees or Independent Contractors Endorsement <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 Healthcare <br />Providers Service Organization for details. <br />Form #: G-141241-BMaster Policy #: 188711433 Named Insured: Charron F AndrewsPolicy #: 0273935164-8 <br />H10412 <br />DocuSign Envelope ID: 8E107476-783D-40A7-92C4-E8E03CD0E84F