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HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> ANA Certificate of *durance omso <br /> nurses service organization <br /> OCCURRENCE POLICY FORM <br /> PRODUCER I BRANCH I PREFIX I POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0312115639-8 From 03/27/12 to 03/27/13 at 12:01 AM Standard Time <br /> Named Insured Program Administered by: <br /> Nurses Service Organization <br /> Janice Galloway 159 E. County Line Road <br /> 6615 Glen Forest Dr Hatboro, PA 19040-1218 <br /> Chapel Hill, NC 27517-8631 1-800-247-1500 <br /> www.nso.com <br /> Medical Specialty Code Insurance is provided by: <br /> _ Registered Nurse -�--- <br /> 80964 American.C sual Com any-of-Reath <br /> ty p ng;-Pennsylvania --- <br /> 333 South Wabash Avenue Chicago, Illinois 60604 <br /> Professional Liability $1,000,000 each claim $6,000,000 aggregate <br /> Your professional liability limits shown above include the following: <br /> • Good Samaritan Liability • Malplacement Liability • Personal Injury Liability <br /> • Sexual Misconduct included in the PL Limit shown above subject to$25,000 aggregate sublimit <br /> Coverage Extensions <br /> License Protection $ 25,000 per proceeding $ 25,000 aggregate <br /> Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate <br /> Deposition Representation $ 10,000 per deposition $ 10,000 aggregate <br /> Assault $ 25,000 per incident $ 25,000 aggregate <br /> Includes Workplace Violence Counseling <br /> Medical Payments $ 25,000 per person $ 100,000 aggregate <br /> First Aid $ 10,000 per incident $ 10,000 aggregate <br /> Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate <br /> Information Privacy(HIPAA)Fines&Penalties $ 25,000 per incident $ 25,000 aggregate <br /> Workplace Liability <br /> Workplace Liability Included in Professional Liability Limit shown above <br /> Fire and Water Legal Liability Included in the PL limit above subject to$150,000 aggregate sublimit <br /> Personal Liability $1,000,000 aggregate <br /> Total:$106.00 <br /> Premium reflects employed, full-time rate. <br /> Policy Forms&Endorsements (Please see attached list for a general description of many common policy forms and endorsements.) <br /> G-121500-D G-121501-C G-121503-C G-145184-A G-147292-A GSL3886 GSL3908 GSL13424 <br /> GSL15563 GSL15564 GSL15565 GSL17101 G-123846-C32 GSL10546NC <br /> 4e4.4tn•i•o442C 1144 .04Q. cp1-44/14 7A1‘14 <br /> Chairman of the Board Secretary <br /> Keep this Certificate of Insurance in a safe place. This Certificate of Insurance and proof of payment are your proof of coverage. <br /> There is no coverage in force unless the premium is paid in full. In order to activate your coverage,please remit premium in full by <br /> the effective date of this Certificate of Insurance. <br /> Form#: G-141241-B (3/2010) Master Policy: 188711433 <br /> no" <br /> • NS0-402-R-NUR-5110811 20120116-015-0000002237 <br />