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DocuSign Envelope ID: FCE3F262-3C43-41 138-130137-AE5E968413477 <br /> Print Date: 11/2712013 <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNA ORGANIZATION PURCHASING GROUP mnso <br /> CCert%ffrate of In5ttra nce <br /> nurses service organization-, <br /> OCCURENCE POLICY FORM <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0597268785 from 11/26113 to 11/26/14 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Vantage Care&Staffing, LLC Nurses Service Organization <br /> 712 Stinhurst Dr 159 E. County Line Road <br /> Durham, NC 27713-7550 Hatboro, PA 19040-1218 <br /> 1-888-288-3534 <br /> www.nso.com <br /> Medical Specialty: Code: Insurance is provided by: <br /> Nursing Firm 80964 American Casualty Company of Reading, Pennsylvania <br /> 333 S. Wabash Avenue, Chicago, IL 60604 <br /> Excludes Cosmetic Procedures <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 S25,000 per proceeding $25,000 aggregate <br /> Defendant Expense Benefit S1,000 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 S100,000 aggregate <br /> First Aid $ 10,000 per incident $ 10;000 aggregate <br /> Damage to Property of Others $ 10,000 per incident S 10;000 aggregate <br /> Information Privacy(HIPAA) Fines and Penalties $ 25,000 per incident S 25;000 aggregate <br /> General Liability <br /> General Liability $1,000,000 each claim 1 $3,000,000 aggregate <br /> Fire &Water Legal Liability Included in the GL limit shown above subject to$250,000 aggregate sublimit <br /> Total: $ 770.00 <br /> Base Premium $770.00 <br /> Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and <br /> endorsements.) <br /> G-121500-D GSL10546NC G-121501-C G-1 45184-A G-147292-A GSL15563 <br /> GSL15564 GSL15565 GSL17101 GSL13424 GSL13425 G-123846-C32 <br /> GSL3886 GSL3908 G-121504-C GSL19904 <br /> Keep this document in a safe place.It <br /> .... and proof of payment are your proof of <br /> coverage. There is no coverage in force <br /> unless the premium is paid in full.In order <br /> to activate your coverage, please remit <br /> Chairman of the Board Secretary premium in full by the effective date of <br /> this Certificate of Insurance. <br /> Master Policy#188711433 <br /> G-141241-8(0312010) Coverage Change Date: Endorsement Change Date: <br />