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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 service@nso.com.

Click here to view sample policy forms for policies renewed after July 1, 2024.

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
Alabama-specific policy forms
CNA100351AL (11-20) - Alabama Punitive Damages Endorsement CNA79516 (07-14) - Enterprise Privacy Protection G-123846-A01 (07-01) - Alabama Cancellation and Non-Renewal
Alaska-specific policy forms
CNA79516AK (10-14) - Enterprise Privacy Protection CNA80052AK (10-14) - Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement - Alaska CNA84018AK (02-16) - Exclusion of Dental Midlevel Provider Procedures Endorsement Alaska CNA85091AK (04-16) - Case Management Services - Alaska CNA90321AK (02-18) - Medicare Medicaid Proceeding Defense - Alaska G-123829-C54 (06-08) - Alaska State Provision G-123846-C54 (07-01) - Alaska Cancellation and Non-Renewal G-123853-C54 (07-01) - Alaska Amendatory Change G-142489-A54 (11-01) - State Endorsement G-142490-A54 (11-01) - State Endorsement G-142870-A54 (07-11) - Alaska State Provision GSL5548AK (06-06) - Case Management Services - Alaska
Arizona-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA96097AZ (10-19) - Amended Definition of Policy Period Endorsement for Arizona G-123846-C02 (07-01) - Arizona Cancellation and Non-Renewal G-123859-C02 (07-01) - Arizona Amendatory Change
Arkansas-specific policy forms
CNA79516AR (07-14) - Enterprise Privacy Protection CNA85091AR (04-16) Case Management Services - Arkansas CNA98115AR (03-20)- Arkansas Policyholder Notice G-123812-C03 (07-01) -Arkansas Amendatory Endorsement G-123846-C03 (07-01) - Arkansas Cancellation and Non-Renewal
California-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-121501-C1 (07-01) -Occurrence Policy Form - California G-121502-C1 (07-01) - Claims Made Policy Form - California G-123846-D04 (07-01) -California Cancellation and Non-Renewal
Colorado-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123815-A05 (07-97)- State Endorsement G-123846-C05 (07-01) - Colorado Cancellation and Non-Renewal
Connecticut-specific policy forms
CNA79516CT (12-14) -Enterprise Privacy Protection CNA88920CT (06-19) - Connecticut Amendatory Change for EPLI CNA88921CT (06-19) - Connecticut Amendatory Change for EPL CNA95181CT (02-19) - Amendment to the Limits of Liability Endorsement - CT G-123812-C06 (07-01) - Connecticut Amendatory Endorsement G-123846-C06 (08-02) - Connecticut Cancellation and Non-Renewal G-142833-A06 (07-02) - State Endorsement G-144933-A06
Delaware-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C07 (07-01) -Delaware Cancellation and Non-Renewal
DC-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C08 (07-01) -District of Columbia Cancellation and Non-Renewal
Florida-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA80989 (12-14) - Concealment, Misrepresentation, Fraud Condition Amendatory Endorsement - Florida CNA81758FL (01-21) - Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA85582FL (04-16) - Florida Cancellation and Non-Renewal CNA88920FL (11-18) - Florida Amendatory Change for EPLI CNA88921FL (11-18) - Florida Amendatory Change for EPL G-123846-D09 (07-01) - Florida Cancellation and Non-Renewal GSL7412FL (06-08) - Florida Amendatory Endorse
Georgia-specific policy forms
CNA79516GA (07-14) - Enterprise Privacy Protection CNA85091GA (04-16) - Case Management Services - Georgia G-123811-C10 (02-02) - Georgia Amendatory Change G-123812-C10 (02-02) - Georgia Amendatory Change G-123846-C10 (07-01) - Georgia Cancellation and Non-Renewal G-123849-E10 (03-11) - Georgia Amendatory Change G-123854-C10 (02-02) - Georgia Amendatory Change G-123855-C10 (02-02) - Georgia Amendatory Change GSL15563GA (02-10) - Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs - GA GSL5548GA (03-06) - Case Management Services - Georgia
Guam-specific policy forms
CNA100725GU (01-21) -Governmental Tort Claim Sub Limit of Liability Endorsement CNA79516 (07-14) - Enterprise Privacy Protection G-123846-GU (1-21) - GU Cancellation & Non-Renewal Endorsement
Hawaii-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C52 (07-01) - Hawaii Cancellation and Non-Renewal
Idaho-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C11 (07-01) - Idaho Cancellation and Non-Renewal
Illinois-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA88921IL (12-18) - Illinois Amendatory Change for EPL G-123812-A12 (09-04) - State Endorsement G-123829-D12 (05-11) - Illinois State Provision G-123846-C12 (07-01) - Illinois Cancellation and Non-Renewal
Indiana-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-121493-B13 (07-01) - Indiana Consent to Settle G-123846-C13 (07-01) - Indiana Cancellation and Non-Renewal
Iowa-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C14 (07-01) - Iowa Cancellation and Non-Renewal
Kansas-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C15 (07-01) - Kansas Cancellation and Non-Renewal G-123856-C15 (07-01) - Kansas Amendatory Change
Kentucky-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA96821KY (09-19) - Policy Holder Notice - Kentucky Surcharge-Firefighters and Law Enforcement Officials Fund G-123846-C16 (07-01) - Kentucky Cancellation and Non-Renewal
Louisiana-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-121487-B17 (06-02) - Louisiana Amendment of Certificate of Insurance G-121493-B17 (06-02) - Louisiana Consent to Settle G-123846-D17 (02-02) - Louisiana Cancellation and Non-Renewal G-124776-C17 (02-02) - Louisiana Pollution Exclusion G-124777-C17 (06-02) - Louisiana Amendatory Change G-137711-B17 (09-02) - Louisiana Amendatory Endorsements G-141236-A17 (09-02) - Louisiana Exclusion of Activities GSL13424LA (10-09) - Services to Animals - Louisiana GSL13432LA (10-09) - Exclusion of Specified Wellness Modalities - Louisiana GSL15564LA (03-10) - Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion - LA GSL2542LA (10-09) - Exclusion of Procedures Treatments or Therapies - Acupuncturist - Louisiana
Maine-specific policy forms
CNA78982ME (11-18) - Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion CNA79516 (11-14) - Enterprise Privacy Protection CNA88920ME (12-18) - Maine Amendatory Change for EPLI G-123816-C18 (07-01) - Maine Amendatory Change G-123846-A18 (11-01) - Maine Cancellation and Non-Renewal
Maryland-specific policy forms
CNA79516 (02-15) - Enterprise Privacy Protection CNA79802MD (08-14) - Maryland Policyholder Notice CNA81758MD (01-21) - Notice - Offer of Terrorism Coverage & Disclosure of Premium G-123846-C19 (01-02) - Maryland Cancellation and Non-Renewal
Massachusetts-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA81758MA (01-21) - Notice - Offer of Terrorism Coverage & Disclosure of Premium G-123846-D20 (07-01) - Massachusetts Cancellation and Non-Renewal
Michigan-specific policy forms
A79516 (07-14) - Enterprise Privacy Protection G-123846-C21 (07-01) - Michigan Cancellation and Non-Renewal G-144292-A (03-03) - Notice to Exempt Commercial Policy Holders Deregulation Forms & Rates
Minnesota-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA88920MN (01-19) - Minnesota Amendatory Change for EPLI G-123525-A22 (06-97) - Minnesota Insurance Guaranty Association Law G-123846-D22 (07-01) - Minnesota Cancellation and Non-Renewal G-135678-C22 (07-01) - Minnesota Amendatory Change
Mississippi-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C23 (07-01) - Mississippi Cancellation and Non-Renewal GSL15563MS (02-10 ) - Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs - MS
Missouri-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-D24 (07-01) - Missouri Cancellation and Non-Renewal
Montana-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA88921MT (11-18) - Montana Amendatory Change for EPL G-123846-C25 (12-01) - Montana Cancellation and Non-Renewal G-123857-C25 (07-01) - Montana Amendatory Change G-123858-C25 (12-01) - Montana Amendatory Change
Nebraska-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123816-C26 (07-01) - Nebraska Amendatory Change G-123829-B26 (07-01) - Nebraska State Provision G-123846-C26 (07-01) -Nebraska Cancellation and Non-Renewal
Nevada-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA88920NV (12-18) - Nevada Amendatory Change for EPLI CNA88921NV (12-18) - Nevada Amendatory Change for EPL G-123816-C27 (12-01) - Nevada Amendatory Change G-123846-C27 (07-01) - Nevada Cancellation and Non-Renewal
New Hampshire-specific policy forms
CNA79516NH (12-14) - Enterprise Privacy Protection CNA88920NH (11-18) - New Hampshire Amendatory Change for EPLI CNA88921NH (11-18) - New Hampshire Amendatory Change for EPL G-123846-C28 (07-01) - New Hampshire Cancellation and Non-Renewal G-123850-D28 (07-01) - New Hampshire Amendatory Change G-123851-B28 (01-02) - New Hampshire Amendatory Change
New Jersey-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C29 (07-05) - New Jersey Cancellation and Non-Renewal GSL13424NJ (07-09) - Services to Animals - New Jersey
New Mexico-specific policy forms
CNA72370 (01-13) - Extended Reporting Period with Reinstatement of Limits CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C30 (07-01) - New Mexico Cancellation and Non-Renewal
New York-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA85091NY (04-16) - Case Management Services - New York G-123813-C31 (01-02) - New York Amendatory Change G-123821-C31 (01-02) - New York Amendatory Change G-123822-D31 (01-02) - New York Amendatory Change G-123846-D31 (07-01) - New York Cancellation and Non-Renewal G-142489-A31 (01-02) - Addendum to the Certificate of Insurance (Claims Made) Policy Holder GSL10550NY (07-08) - New York Amendatory Endorsement GSL11346NY (12-09) - Prior Acts Errors or Omissions Endorsement GSL11892NY (03-09) - New York Amendatory Endorsement GSL11893NY (03-09) - New York Amendatory Endorsement GSL15563NY (04-10) - New York Information Privacy Coverage GSL15565NY (04-10) - New York Assault Coverage GSL18064NY (08-10) - New York Amendatory Endorsement GSL5548NY (02-10) - Case Management Services - New York GSL5587NY (02-10) - Consulting Services Liability Endorsement - New York
North Carolina-specific policy forms
CNA72370 (01-13) - Extended Reporting Period with Reinstatement of Limits CNA79516NC (10-14) - Enterprise Privacy Protection CNA88920NC (11-18) - North Carolina Amendatory Change for EPLI CNA88921NC (11-18) - North Carolina Amendatory Change for EPL G-123815-C32 (07-01) - North Carolina Extended Reporting Period G-123846-C32 (07-01) - North Carolina Cancellation and Non-Renewal GSL10546NC (06-08) - North Carolina Amendatory Endorsement
North Dakota-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C33 (07-01) - North Dakota Cancellation and Non-Renewal
Ohio-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C34 (07-01) - Ohio Cancellation and Non-Renewal
Oklahoma-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-B35 (07-01) - Oklahoma Cancellation and Non-Renewal G-142833-A35 (07-02) - Oklahoma Claims-Made Amendatory Endorsement
Oregon-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C36 (07-01) - Oregon Cancellation and Non-Renewal
Pennsylvania-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123812-A37 (11-01) - Pennsylvania Amendatory Change G-123846-C37 (11-01) - Pennsylvania Cancellation and Non-Renewal G-123847-C37 (07-01) - Pennsylvania Extended Reporting Period
Puerto Rico-specific policy forms
CNA72370 (01-13) - Extended Reporting Period with Reinstatement of Limits CNA79516 (07-14) - Enterprise Privacy Protection CNA94164PR (04-19) - Amendment Definition of Claim Endorsement G-123846-A58 (06-04) - Puerto Rico Cancellation and Non-Renewal GSL13424PR (10-09) - Services to Animals - Puerto Rico
Rhode Island-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123815-C38 (07-01) - Rhode Island Amendatory Change G-123846-C38 (07-01) - Rhode Island Cancellation and Non-Renewal
South Carolina-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA85091SC (05-16) - Case Management Services - South Carolina G-123846-C39 (07-01) - South Carolina Cancellation and Non-Renewal
South Dakota-specific policy forms
CNA79516SD (11-14) - Enterprise Privacy Protection G-123846-C40 (07-01) - South Dakota Cancellation and Non-Renewal
Tennessee-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123811-C41 (07-01) - Tennessee Amendatory Change G-123812-C41 (07-01) - Tennessee Amendatory Change G-123828-B41 (10-01) - Tennessee Notice of Cancellation G-123846-C41 (07-01) - Tennessee Cancellation and Non-Renewal G-123854-C41 (07-01) - Tennessee Amendatory Change G-123855-C41 (07-01) - Tennessee Amendatory Change
Texas-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA80079TX (07-16) - Texas Policyholder Notice CNA97490TX (01-20) - Texas Policy Holder Notice G-123846-C (08-16) - Texas Cancellation and Non-Renewal
Utah-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C43 (07-01) - Utah Cancellation and Non-Renewal
Vermont-specific policy forms
CNA72370 (01-13) - Extended Reporting Period with Reinstatement of Limits CNA79516 (07-14) - Enterprise Privacy Protection CNA84126VT (03-16) - Deletion of Asbestos Exclusions CNA85189VT (03-16) - Vermont Changes - Pollution CNA88920VT (11-18) - Vermont Amendatory Change for EPLI CNA88921VT (11-18) - Vermont Amendatory Change for EPL G-123846-C44 (11-15) - Vermont Cancellation and Non-Renewal
Virgin Islands-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA81758VI (01-21) - Notice - Offer of Terrorism Coverage & Disclosure of Premium G-123846-A64 (01-21) - Virgin Island Cancellation and Non-Renewal
Virginia-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123846-C45 (07-01) - Virginia Cancellation and Non-Renewal
Washington-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123811-C46 (02-02) - Washington Amendatory Change G-123812-C46 (02-02) - Washington Amendatory Change G-123846-C46 (02-02) - Washington Cancellation and Non-Renewal G-123854-C46 (02-02) - Washington Amendatory Change G-123855-C46 (02-02) - Washington Amendatory Change
West Virginia-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection CNA88920WV (01-19) - West Virginia Amendatory Change for EPL CNA88921WV (01-19) - West Virginia Amendatory Change for EPL G-123846-C47 (07-01) - West Virginia Cancellation and Non-Renewal
Wisconsin-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection G-123812-C48 (07-01) - State Endorsement G-123846-C48 (07-01) - Wisconsin Cancellation and Non-Renewal
Wyoming-specific policy forms
CNA79516 (07-14) - Enterprise Privacy Protection. G-123846-C49 (07-01) - Wyoming Cancellation and Non-Renewal
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.