CTR077255_COI.PDF
PDF 100 KB Posted
- Attached to
- Master Agreement AZ|CTR077255
- Contract number
- CTR077255
- Issued by
- Arizona
About this file
This document is a professional liability insurance policy certificate issued by Healthcare Providers Service Organization (HPSO), a trade name of Affinity Insurance Services, Inc., for Jennifer McChristian, a social worker located in Indianapolis, Indiana. The policy is underwritten by American Casualty Company of Reading, Pennsylvania, and covers professional liability for the insured individual across multiple states, with specific regulatory considerations noted for New Jersey, Kentucky, West Virginia, and Florida.
The insurance policy provides professional liability coverage with a $1,000,000 per incident limit and a $3,000,000 aggregate limit, effective from 05/07/24 to 05/07/25. The base premium is $821.00 and includes various coverage elements such as workplace liability, good samaritan liability, personal injury liability, and sexual misconduct coverage. Additional endorsements cover areas like information privacy, healthcare provider professional liability assault, and exclude specific activities like cosmetic procedures. The policy also includes media expense coverage with a $25,000 per incident and aggregate limit, and incorporates provisions for terrorism coverage and entity exclusions.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
1100 Virginia Drive, Suite 250 Fort Washington, PA 19034-3278 Phone:1-800-982-9491 Fax:1-800-758-3635 Website:www.hpso.com
Dedicated To Serving The Insurance Needs of Healthcare Providers Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA & MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services Inc.;
in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.
1-800-982-9491
12/16/24
Jennifer McChristian 529 Tanninger Dr Indianapolis, IN 46239-9457
Jennifer McChristian:
25,000 25,000
Media Expense per incident aggregate$ 25,000 $ 25,000
Print Date: 12/16/2024
0715840750 05/07/24 to 05/07/25 at 12:01 AM Standard Time
Jennifer McChristian 529 Tanninger Dr Indianapolis, IN 46239-9457
American Casualty Company of Reading, PennsylvaniaSocial Worker, Clinical 80723
Excludes Cosmetic Procedures
1,000,000 3,000,000
821.00 Base Premium $821.00
Healthcare Providers Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034 1-800-982-9491 www.hpso.com
CNA93692 (11-2018)
12/16/2024 12/16/2024
Workplace Liability Workplace Liability Fire & Water Legal Liability Personal Liability
Included in Professional Liability Limit shown above Included in the PL limit shown above subject to aggregate aggregate sublimit $1,000,000
$150,000
Premium reflects Self Employed , Full Time
* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit
G-121500-D (04-08) Common Policy Conditions G-121503-C (07-01) Workplace Liability Form G-121501-C (07-01) Occurrence Policy Form CNA94164 (11-18) Amendment Definition of Claim Endorsement G-145184-A (06-03) Policyholder Notice - OFAC Compliance Notice G-147292-A (03-04) Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 (02-10) Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 (10-09) Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 (03-10) Healthcare Providers Professional Liability Assault Coverage GSL17101 (02-10) Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 (05-09) Services to Animals CNA80051 (09-14) Amended Definition of Personal Injury Endorsement CNA80052 (09-14) Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G-123846-C13 (07-01) Indiana Cancellation and Non-Renewal CNA81753 (03-15) Coverage & Cap on Losses from Certified Acts Terrorism CNA81758 (01-21) Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA82011 (04-15) Related Claims Endorsement CNA89027 (10-17) Entity Exclusion Endorsement CNA79575 (07-14) Exclusion of Cosmetic Procedures G-141231-A (07-01)(03)Additional Insured Healthcare Entity CNA89026 (05-17) Media Expense Coverage
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association.
For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax.
As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been applied to your insurance premium and is separately itemized on the Declarations page or billing instrument attached to your policy, as required KRS. §136.392.
For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
For FL residents:
CNA93692 (11-2018)
0715840750
Jennifer McChristian
File details come from the government source that posted it. Updated .