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HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> CNA (ertif irate of 3muranct Knso <br /> nurses serAm orpir.:atirxr. <br /> OCCURRENCE POLICY FORM <br /> PRODUCER I BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 1 970 HPG 0596951183-8 From 10/01/13 to 10/01114 at 12:01 AM Standard Time <br /> Named insured Prooram Administered by: <br /> Nurses Service Organization <br /> Janet Whitesides 159 E. County Line Road <br /> 107 Center St Hatboro, PA 19040-1218 <br /> Carrboro, NC 27510-1735 1-800-247-1500 <br /> www.nso.com <br /> Medical Siaecialty Cade Insurance is provided by: <br /> Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania <br /> 333 South Wabash Avenue Chicago, Illinois 60604 <br /> Professional Liabiiity $500,000 each claim $2,500,000 aggregate <br /> Yow professional liability iinits 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 er incident <br /> p $ 25,000 aggregate <br /> lndutks t odplace ftbr ce CourseNng <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 move subject to$150,000 aggregate sublimit <br /> i Personal Liability $500,000 aggregate <br /> i Total:$88.00 <br /> Premium reflects employed, part-time rate. <br /> Policy Forms&Endorsements (Please see attached list for a general description of many common policy forms and endomements.) <br /> G-121500-D G-121501-C G-121503-C G-145184-A G-147292-A GSL3886 GSL3908 GSL13424 GSL15563 <br /> GSL15564 GSL15565 GSL17101 G-123846-C32 GSL10546NC <br /> T. <br /> k;cq ilk •' <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 /> Farm#: G-141241-B(3/2010) Master Policy: 188711433 <br /> tiS6505�1-Nn�i-#!t ZU]3U423dt3 <br />