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Print Date: 7/27/2012 <br /> CNA HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> Certificate of �fiY�nr�iltce mnso <br /> nurses service organtzatwn•- <br /> OCCURENCE POLICY FORM <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0423623038 from 07/06/12 to 07/06/13 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Linda D Cole Nurses Service Organization <br /> 201 Davie Rd Apt A 159 E. County Line Road <br /> Carrboro, NC 27510-1670 Hatboro, PA 19040-1218 <br /> 1-800-247-1500 <br /> www.nso.com <br /> Medical Specialty: Code: Insurance is provided by: <br /> Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania <br /> Excludes Cosmetic Procedures 333 S. Wabash Avenue, Chicago, IL 60604 <br /> Professional Liability $ 500,000 each claim $2,500,000 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 and Penalties $25,000 per incident $25,000 aggregate <br /> Workplace Liability <br /> Workplace Liability Included in Professional Liability Limit shown above <br /> Fire&Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate subiimit <br /> Personal Liability $500,000 aggregate <br /> Total: $ 143.00 <br /> Base Premium $143.00 <br /> Premium reflects Self Employed , Part Time <br /> Policy Forms&Endorsements(Please see attached list for a general description of many common policy forms and <br /> endorsements.) <br /> G-121500-D GSL10546NC G-121503-C G-121501-C G-145184-A G-147292-A <br /> GSLI5563 GSL15564 GSL15565 GSL17101 GSL13424 G-123846-C32 <br /> GSL3886 GSL3908 GSL19904 <br /> Keep this document in a safe piece.It <br /> /. i � � p `I _ and proof of payment are your proof of <br /> oT[ � ll'„U C1�-,r(!-^�- coverage. There is no coverage in force <br /> ' unless the premium is paid in full.In order <br /> Chairman of the Board Secretary to activate your coverage,please remit <br /> premium in full by the effective date of <br /> this Certificate of Insurance. <br /> Master Policy#188711433 <br /> G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: <br />