Sample Policy Forms

To view or download NSO and HPSO’s sample professional liability insurance policy forms, please select your state of residence below. There will be two categories of forms: forms that are applicable to all states, and forms that are specific to each state.  

To determine the appropriate forms, please refer to the list of forms found on Page Two of your Certificate of Insurance, if applicable. Please note that these forms are specimen and do not constitute or replace the terms and conditions of any insurance policy. If you would like to obtain a paper copy of your policy, please email us at

Select your state of residence:
Policy forms for all states
CNA79574 (07-14) - Coverage for Cosmetic Procedures CNA79575 (07-14) - Exclusion of Cosmetic Procedures 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 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 CNA84406 (01-16) - Student Endorsement CNA85091 (04-16) - Case Management Services CNA89026 (05-17) - Media Expense Coverage CNA89027 (10-17) - Entity Exclusion Endorsement CNA94164 (11-18) - Amendment Definition of Claim Endorsement CNA96097 (06-19) - Amended Definition of Policy Period Endorsement G-121486-B (07-01) - Additional Insured Non - Healthcare Entity G-121487-B (07-01) -Amendment to Certificate G-121493-B (07-01) - Consent to Settle G-121500-D (04-08) - Common Policy Conditions G-121501-C (07-01) - Occurrence Policy Form G-121502-C (07-01) - Claims Made Policy Form G-121503-C (07-01) - Workplace Liability Form G-121504-C (07-01) - General Liability Form G-123827-B (07-01) - Additional Insured General Liability G-123828-B (07-01) - Certificate Holder G-141232-A (07-01) - Exclusion of Employed Professional Services G-141232-A17 (09-02) - LA Excl of Empl Prof Services G-141235-A (07-01) - Additional General Liability Locations G-141236-A (07-01) - Exclusion of Activities G-141236-AE (07-01) - Exclusion of Colonics including Colon Hydrotherapy G-141237-A (07-01) - Scheduled Covered Subsidiaries G-145184-A (06-03) - Policyholder Notice - OFAC Compliance Notice G-147292-A (03-04) - Policyholder Notice - Silica, Mold & Asbestos Disclosure G-39543-A - Exclusion of Business Coverage Extension GSL11346 (05-09) -Prior Acts Errors or Omissions Endorsement GSL13424 (05-09) - Service to Animals GSL13425 (05-09) - Business Owner Coverage Extension Endorsement GSL13429 (05-09) - Exclusion of Prescriptive Authority GSL13432 (05-09) -Exclusion of Specified Wellness Modalities GSL13482 (05-09) - Director of Nursing Acting Director of Nursing or Administrator with Sublimits 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 GSL2542 (05-09) - Exclusion of Procedures Treatments or Therapies Acupuncturist GSL-5548 (11-05) - Case Management Services GSL-5587 (11-05) - Consulting Services Liability Endorsement GSL-6720 (10-06) - Fitness Liability Endorsement
This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to AIS, NSO, HPSO websites are provided solely for convenience, and AIS, NSO and HPSO disclaims any responsibility with respect to such websites.  This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.   

Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.