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The Medical Protective Company <br />ASTOCK INS URANCE COMPANY <br />5814 Read Roatl, Fort Wayne, Indiana 46835 <br />Strength. Defense. S'luil crs. Since 1899. <br />MULTI -SPECIALTY HEALTHCARE PROFESSIONAL - CERTIFICATE <br />Policy <br />2021-11-29 TO: 2022-11-29 <br />Certificate Number: U54661 <br />Period: <br />at 12:01 a.m. Standard Tyra at Ne address of Ne First Named Insured. <br />Item 1(a) Named Insured: N/A <br />Student <br />Non -Insured acting in the capacity of an Administrative <br />First Named Insured <br />Ellensburg Family Medicine <br />Professional Services Specialty: NP Group <br />Classification: N/A <br />Item 1(b) Additional Insureds: <br />First Named Insured Address: <br />2156 PAYNE RD <br />New Business I X <br />Renewal Business <br />ELLENSBURG, WA 98926-7898 <br />POLICY TYPE* <br />RETROACTIVE <br />LIMITS OF LIABILITY <br />Citc,nrn,nos <br />standard <br />Converi <br />COVERAGES: <br />DATE <br />Claims Made <br />Claims Made <br />Per Claim Aggregate <br />PROFESSIONAL LIABILITY <br />$1,000,000 $6,000,000 <br />A. Professional Liability (PL) & <br />Included Included <br />B. Good Samaritan Acts <br />$25,000 $25,000 <br />C. Assault Upon You <br />$15,000 $15,000 <br />D. First Aid <br />$25,000 $100,000 <br />E. Medical Payments <br />X <br />$10,000 $10,000 <br />F. Deposition Fees <br />- Administrative Hearing Expense <br />$25,000 $100,000 <br />- Sexual Misconduct Expense <br />$25,000 $25,000 <br />- Loss of Earnings <br />$2,500 $35,000 <br />- HIPAA Proceeding Expense <br />$25,000 $25,000 <br />- Biomedical Waste Hearing Expense <br />$10,000 $10,000 <br />WORKPLACE LIABILITY <br />A. Healthcare Professional Premises <br />Liability & <br />B. Personal Injury Liability <br />WaAplmvL.fii, nanotapplyir Me tiomm eldirylimm Agnemenliamd,amlo(yp,r <br />voa,. <br />EMPLOYMENT PRACTICES LIABILITY" <br />CYBER LIABILITY <br />BILLING PRACTICES & REGULATORY <br />COMMERCIAL GENERAL LIABILITY <br />- Each Occurrence Limit <br />$1,000,000 <br />- Damages to Premises Rented <br />$1,000,000 <br />to an Insured Business <br />$1,000,000 <br />- Personal & Advertising Injury X <br />$6,000,000 <br />- General Aggregate Limit <br />- Product Completed Operations Aggregate <br />$6,000,000 <br />- Hired and Non -Owned Auto <br />General Liability dam not apply If Me Wodplace Ualmity moving Agreement is mad. Wrr oryoor coy <br />made <br />FORMS & ENDORSEMENTS: <br />Master Policy Number: MMPOC19190 <br />IN W 7NEEs5 WHEREOF, The Medial Protective Cannery has ra. ped this <br />policy W be signaJ by its President and Corporate secretary (and <br />SEE POLICY FORMS & ENDORSEMENTS SCHEDULE <br />countersigned by its duty Auf rzed Remassntates. where neceesary). <br />President <br />Premium: $4,932.00 <br />For Service or questions, please call: <br />Surcharges: $0.00 <br />CM&F Group, Inc. 1-800-221-4904 <br />1 <br />',LJY"Ck4. n0� <br />Taxes: $0.00 <br />TOTAL: $4.932.00 <br />1 <br />Secretary <br />*THIS POLICY CONTAINS CLAIMS -MADE COVERAGE. <br />countersignature l Aummmed Representative <br />** CLAIM EXPENSE IS PAID WITHIN THE LIMITS OF LIABILITY. <br />NOTICE <br />LIMITS MAY CHANGE BY COVERAGE PROVISION OR ENDORSEMENT. <br />PLEASE READ YOUR POLICY AND ENDORSEMENTS CAREFULLY. <br />DISCUSS WITH YOUR INSURANCE AGENT IF NEEDED. <br />18011 01114 <br />