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DocuSign Envelope ID: 30CC97DC-995F-48ED-9245-A640EBC3CAOC <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNAORGANIZATION PURCHASING GROUP mnso <br /> Certificate of 3 i%u aillre nurses service orpnizatinn <br /> OCCURENCE POLICY FORM Print pate: 2109/2015 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0428064583 from 02118115to 02/18/16 at 12.01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Colleen Black Semelka Nurses Service Organization <br /> 265 Severin St 159 E. County Line Road <br /> Chapel Hill, NC 27516-1511 Hatboro, PA 1 9040-1 21 8 <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 /> 333 S-Wabash Avenue, Chicago, IL 60604 <br /> Professional Liability $1,004,000 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 S25,000 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 sublimit <br /> Personal Liability $1,000,000 aggregate <br /> Total: $ 102.00 <br /> Base Premium $102.00 <br /> Premium reflects Employed , Part Time <br /> Policy Forms &End orsements(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 /> GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 G-123846-C32 <br /> GSL3888 GSL3908 <br /> Keep this document in a safe place.9 <br /> p and proof of payment are your proof of <br /> i j� ,1 „f coverage. There is no coverage in force <br /> �J r u ill --- "`--- unless the premium is paid in full.In order <br /> Chairman of the Board <br /> Sec to activate your coverage, please remft <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 />