Specimen
HEALTHCARE PROVIDERS
PROFESSIONAL LIABILITY INSURANCE ENDORSEMENT
TENNESSEE AMENDATORY CHANGE
ENDORSEMENT
It is hereby agreed that policy section IV. Exclusions (under form G-121504-C [7/2001]) item J. is deleted and replaced
by the following:
J.
the return or withdrawal of fees or government payments imposed directly upon you; any fines, penalties or
sanctions;
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown
below. All other provisions of the policy remain unchanged.
G-123812-C41(7/01)
Complete Only When This Endorsement Is Not Prepared with the Policy
Or Is Not to be Effective with the Policy
ISSUED TO
ENDORSEMENT EFFECTIVE DATE
Must Be Completed
ENDT. NO.
1
POLICY NO.
