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DocuSign Envelope ID:9C6ODO4C-lEF6-4EOD-BD1A-7558114637A2 <br /> HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> CNA Certificate of Iuturauce �- �PSO_ <br /> jHhb .: ass:P—id-8—keb i.ti n <br /> OCCURRENCE POLICY FORM <br /> PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0273935164-8 From 07/27/15 to 07/27/16 at 12:01 AM Standard Time <br /> Named Insured Program Administered by: <br /> Healthcare Providers Service Organization <br /> Charron F Andrews 159 E. County Line Road <br /> 108 Cottonwood Ct Hatboro, PA 1 9040-1 21 8 <br /> Chapel Hill, NC 27514-1629 1-800-982-9491 <br /> www.hpso.com <br /> Medical Specialty Code Insurance is provided by: <br /> Physical Therapist 80995 American Casualty Company of Reading, Pennsylvania <br /> (Medical Specialty is amended to include Consulting Services) <br /> 333 South Wabash Avenue Chicago, Illinois 60604 <br /> Professional Liability $1,000,000 each claim $3,000,000 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:$182.00 <br /> Premium reflects employed,full-time rate. <br /> I, <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 GSL-5587 <br /> I <br /> Chairman of the Board Secretary I <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 i <br /> the effective date of this Certificate of Insurance. <br /> j <br /> I <br /> Form#: G-141241-B(3/2010) Master Policy: 188711433 <br /> j <br /> r. <br /> }'I <br /> HPSO-504-R-PHY-H3 20150525-561 <br /> I' <br />