1100 Virginia Drive, Suite 250
Fort Washington, PA 19034-3278
Phone:1-800-982-9491 Fax:1-800-758-3635
Website:www.hpso.com
07/26/24
Stephan G Chiarini
10241 Sw 103rd Ct
Miami, FL 33176-3518
Stephan G Chiarini:
1-800-982-9491
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.
Print Date: 7/26/2024
0423740621 07/26/24 to 07/26/25 at 12:01 AM Standard Time
Stephan G Chiarini Healthcare Providers Service Organization
10241 Sw 103rd Ct 1100 Virginia Drive, Suite 250
Miami, FL 33176-3518 Fort Washington, PA 19034
1-800-982-9491
www.hpso.com
Marriage/Family Counselor 80723 American Casualty Company of Reading, Pennsylvania
Excludes Cosmetic Procedures
1,000,000 5,000,000
* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit
25,000 25,000
Media Expense $ 25,000 per incident $ 25,000 aggregate
Workplace Liability
Workplace Liability Included in Professional Liability Limit shown above
Fire & Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit
Personal Liability $1,000,000aggregate
213.11
Base Premium $ 211.00 FIGA Emergency $ 2.11
Premium reflects Self Employed , Part Time
CNA93692 (11-2018)
G-121500-D (04-08) Common Policy Conditions
G-121501-C (07-01) Occurrence Policy Form
G-121503-C (07-01) Workplace Liability Form
CNA82011 (04-15) Related Claims Endorsement
G-145184-A (06-03) Policyholder Notice - OFAC Compliance Notice
G-147292-A (03-04) Policyholder Notice - Silica, Mold & Asbestos Disclosure
CNA81753 (03-15) Coverage & Cap on Losses from Certified Acts Terrorism
CNA81758FL (01-21) Notice - Offer of Terrorism Coverage & Disclosure of Premium
GSL13424 (05-09) Services to Animals
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
CNA80052 (09-14) Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
CNA80051 (09-14) Amended Definition of Personal Injury Endorsement
CNA94164 (11-18) Amendment Definition of Claim Endorsement
CNA80989 (12-14) Concealment, Misrepresentation, Fraud Condition Amendatory Endorsement - Florida
CNA85582FL (04-16) Florida Cancellation and Non-Renewal
CNA79575 (07-14) Exclusion of Cosmetic Procedures
CNA89026 (05-17) Media Expense Coverage
CNA89027 (10-17) Entity Exclusion Endorsement
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: The surcharge shown on the Certificate of Insurance is the FL Insurance
Guaranty Association Emergency Assessment
CNA93692 (11-2018) Stephan G Chiarini
0423740621
