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DocuSign Envelope ID: 1F60E2EA- F83B -41 CE-BF1 1-1 370E9736968 <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROUP <br />CNA certificate of kfsurance ns' <br />nurses service organization <br />OCCURRENCE POLICY FORM <br />PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br />018098 970 HPG 0617869543 -8 From 04/22/15 to 04/22/16 at 12:01 AM Standard Time <br />Named Insured Program Administered by: <br />Nurses Service Organization <br />Jennifer Sugg 159 E. County Line Road <br />PO Box 272 Hatboro, PA 19040 -1218 <br />Bynum, NC 27228 -0272 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 $1,000,000 each claim $6,000,000 aggregate <br />Your prc`.essiond 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: $53.00 <br />Premium reflects employed, full -time rate with recent graduate discount. <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 GSL15563 GSL15564 <br />GSL15565 GSL17101 CNA80052 CNA80051 G- 123846 -C32 GSL10546NC <br />K O v�ra� 4r "'al ice- v y�11'ii 4—% <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 />