Sample Certificate of Insurance

Policy Number Policy Period
Your policy number is listed here Your coverage effective dates are here
Named Insured and Address: Program Administrator:
Your name
Your address
Healthcare Providers Service Organization
1100 Virginia Drive
Fort Washington, PA 19034
Medical Speciality:  
Your Profession  
Code: Insurance Provided by:
HPSO code for your profession American Casualty Company of Reading, Pennsylvania
151 N.Franklin Street
Chicago, IL 60606
   
COVERAGE PARTS LIMITS OF LIABILITY
A. PROFESSIONAL LIABILITY
  Professional Liability (PL) each claim aggregate
  Good Samaritan Liability included above  
  Personal Injury Liability included above  
  Sexual Misconduct   aggregate sublimit
B. Coverage Extensions:
  License Protection per proceeding aggregate
  Defendant Expense Benefit per day limit aggregate
  Deposition Representation per deposition aggregate
  Assault (Includes Workplace Violence Counseling) per incident aggregate
  Medical Payments per person aggregate
  First Aid per incident aggregate
  Damage to Property of Others per incident aggregate
  Media Expense per incident aggregate
  Information Privacy (HIPAA) Fines and Penalties per incident aggregate
C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy.
  Workplace Liability  
  Fire & Water Legal Liability   sub-limit
  Personal Liability   aggregate
D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy.
  General Liability   aggregate
  Fire & Water Legal Liability   sub-limit
  Personal Liability   aggregate
 
Total Premium: your premium amount
Policy forms and endorsements attached at inception:
Policy Forms & Endorsements: This will be a list of the documents that make up your policy booklet. Click here to read and print specimen copies of your policy booklet.

*Each Claim

This is the maximum amount available to be paid on your behalf if a demand for money or services is made alleging injury or damage arising from a single act, error or omission in the rendering of your professional services as stated on your certificate of insurance.

**Aggregate

This is the maximum amount available to be paid on your behalf regardless of the number of claims or entities making claims against you.

The Bottom Line: the most we will pay for any single covered malpractice lawsuit is the each claim limit. The total amount we will pay for all covered malpractice lawsuits will not exceed the aggregate limit.

Coverage Parts

A. PROFESSIONAL LIABILITY COVERAGE PART

Professional Liability (PL)

Provides coverage for amounts up to the limits stated on your certificate of insurance that you become legally obligated to pay as a result of a professional liability claim arising out of a covered medical incident.

Personal Injury

Coverage for charges of privacy violation, slander, libel, and other alleged personal injuries committed while carrying out your professional duties.

Sexual Misconduct

Coverage is provided up to the limit stated on your certificate of insurance, as a sublimit of professional liability, for amounts that you are legally obligated to pay as a result of covered claims involving acts of sexual misconduct related to professional services, provided that there is no determination of liability. There is no coverage for criminal acts, including consensual sexual activity. (This coverage is not available in New York).

B. COVERAGE EXTENSIONS

License Protection

If a complaint is submitted against you to an applicable licensing agency, you could face the challenge of defending your practice and license. A policy through HPSO will reimburse you up to $25,000 in aggregate for your legal representation arising out of a covered license protection incident.

Defendant Expense Benefit

Your policy through HPSO will reimburse you up to the limits stated on your certificate of insurance for lost wages and other covered expenses incurred when you are required to attend a trial, hearing, or proceeding as a defendant in a covered claim.

Deposition Representation

If you receive a subpoena for documents or testimony arising out of professional services related to a lawsuit in which you are not named, the HPSO policy includes deposition representation. Your coverage through HPSO will pay for attorney’s fees charged by an attorney designated by the insurer to prepare you for a deposition.

Assault Coverage

If you become the victim of an assault, either at or while commuting to or from your workplace, this coverage provides reimbursement up to $25,000 annual aggregate, for your covered medical expenses or damage to your personal property. (This coverage is not available in Texas).

Medical Payments

Up to the limits stated on your certificate of insurance for reimbursement of necessary medical expenses incurred by others injured at your residence or business premises as a result of a covered incident, other than a medical incident.

First Aid

This coverage reimburses you up to the limits stated on your certificate of insurance for expenses you incur in rendering first aid to others.

Damage to Property of Others

Payment up to $10,000 annual aggregate for unintentional damage you cause to someone else’s property while at your residence or your workplace.

Information Privacy (HIPAA) Fines and Penalties

The HIPAA provision reimburses you up to $25,000 aggregate to notify patients of a breach of confidential personal information in violation of privacy protection laws. It also covers HIPAA fines and penalties that you become legally obligated to pay as a result of a covered proceeding. (Fines and penalties not available in New York).

Media Expenses

Coverage is provided up to $25,000 annual aggregate for certain fees, such as third party legal or public relations consultants, to address adverse publicity or media attention, including preparation of statements, press releases, and interviews arising from your profession services. (Coverage is not available in all states).


Claims will be evaluated for coverage based upon the specific facts and circumstances presented, the issued policy terms, conditions and exclusions. If coverage is afforded, the amounts payable under a policy are subject to applicable deductibles and limits of insurance. An interpretation of coverage does not predict the outcome of a claim.