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DocuSign Envelope ID:862A1C76-E42E-48F6-B579-DC059294685A <br /> i <br /> DocuSign Envelope ID:401935FF-93EC-462C-9FB0-D487E3C12B7B <br /> HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP m <br /> CN, A 4 <br /> ( urtmcate of 3w;uran re SS <br /> nurses service organization <br /> OCCURRENCE POLICY FORM <br /> PRODUCER IBRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0151867559-8 From 03/03/15 to 03/03/16 at 12:01 AM Standard Time <br /> Named Insured Prog_ram Administered by: <br /> i <br /> Nurses Service Organization <br /> Daniel L Leonard 159 E. County Line Road <br /> 105 Keith Rd Hatboro, PA 19040-1218 <br /> Carrboro, NC 27510-1929 1-800-247-1500. <br /> I <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 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 /> . i <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:$106.00 <br /> Premium reflects employed,full-time rate. <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 <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-141241-B (3/2010) Master Policy: 188711433 <br /> i'r NSO-604-N-NUR-N1 20141222-016-001705 13635 <br />