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DocuSign Envelope ID:74F011EB-23A7-4767-91C1-8E4C25122630 <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 /> 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 /> 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-B Named Insured: Charron F Andrews <br /> Master Policy#: 188711433 Policy#: 0273935164-8 <br /> H10412 <br />