PROOF OF INSURANCE (2011) CLOSEDFrom:HMH E.R. ADMINISTRATION 626 397 2931
HEALTHCARE PROVIDERS SERVICE
NA ORGANIZATION PURCHASING GROUP
»~rtiffcate of Inourante
OCCURENCE POLICY FORM
Producer Branch Prefix Policy Number
018098 970 HPG 0427783195
Named Insured and Address:
Jennifer L Van Slyke
953 S Marengo Ave
Pasadena, GA 91108 -4253
Medical Specialty: Code:
Registered Nurse 80964
1211712010 13:30 #030 P.0021003
Print Date: 1 2/1 6/2010
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Policy Period
from 12/20/10to 12/20111 at 12:01 AM Standard Time
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Insurance is provided by:
American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 90804
Professional Liability
$1,000,000 each claim
$ 3,000,000
aggregate
Your professional liability limits shown above include the following:
• Good Samaritan Liability
* Malplacement Liability Personal Injury
Liability
• sexual Misconduct Included
In the PL limit shown above subject to $ 25,000 aggregate
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Coverage Extensions
License Protection
$ 25,000 per proceeding
$ 25,000
aggregate
Defendant Expense Benefit
$1,000 per day limit
$ 25 „000
aggregate
Depoeltion Representation
$10,000 per depoeltion
$10,000
aggregate
Assault
$ 25,000 per incident
$ 20,000
aggregate
Includes Workplace Violence Counseling
Medical Payments $ 25,004 per person
$100,000
aggregate
First Aid
$ '10,000 per Incident
$ 10,004
aggregate
Damage to the Property of Others
$10,000 per incident
$ 10,000
aggregate
Information Prlvaoy (HIPAA) Fines
and Penalties $ 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
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Personal Liability
$1,000,000 aggregate
Tc al: $ 94.00
Base Premium $94.00
Premium reflects Employed, Full Time
Policy Forma & Endorsements(Please sae attached list for the general description of policy forms that may or may not
apply to this policy)
From:HMH E.R. ADMINISTRATION 626 397 2981 1211712010 13:30 #030 P.0031003
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This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified
vehicles end named insureds and may peoWde coverage Cor a^+Clter
peraws and other vehicles as ptovided by the insurance pokey,
VEHICLES ON POLICY
YEAR MAKE VEH I.D. #
2010 HOND 2HGFA1F52AH584612
2005 TOYO 6TDZA22C35S380916
DRIVERS ON POLICY
VANSLYKE, JENNY
VANSLYKE, JAMES
December 22, 2010
Martha Dijkstra
Human Resources Department
City of El Segundo
350 Main Street
El Segundo, California 90245
RE: Workers' Compensation Insurance
Dear Ms. Dijkstra:
Due to the fact that Jenny Van Slyke RN is self - employed and does not have any
employees, Workers' Compensation insurance is not warranted and has not been
obtained.
Cordially, . w..
Jenny Vail Slyke,/