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HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> CN! A (Certif'caste of ksura�e innso <br /> � OCCURRENCE POLICY FARM <br /> l! PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0596951183-8 From 10/01113 to 10/01/14 at 12:01 AM Standard Time <br /> Named Insured Program 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 Specialty Code Insurance is provided by: <br /> Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania <br /> 333 South Wabash Avenue Chicago, Illinois 60604 <br /> Professional Liability $500,000 each claim $2,500,000 aggregate <br /> Your professional riabHity Urnits shown above induce 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 Woriplace 14clence 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 $500,000 aggregate <br /> Total•$88.00 <br /> Premium reflects employed,part-time rate. <br /> Policy Forms&Endorsements (Please see aHached list for a general description:of many common policy fonts and endorsenents.) <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 /> 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-14124'1-8(3/2010) Master Policy: 188711433 <br /> t1S6'215fi!-HIR-tit 1�13097S-0f3 <br />