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DocuSign Envelope ID:78F206FF-A138-4129-88A7-AC03812E2BD1 <br /> .,, —OVIDERS SERVICE <br /> CNAORGANIZATION PURCHASING GROUP MHPSO <br /> (Certificate of 3Snorance HeAtheare Providers Service Ornanization- <br /> OCCURENCE POLICY FORM Print Date: 8/10/2015 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0613252987 from 06/15/15 to 06/15/16 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Institute of Art Therapy, Inc. dba The Art Thera Healthcare Providers Service Organization <br /> Institute 159 E. County Line Road <br /> 200 N Greensboro St Ste D6 Hatboro, PA 19040-1218 <br /> Carrboro, NC 27510-1849 1-888-288-3534 <br /> www.h pso.com <br /> Medical Specialty: Code: Insurance is provided by: <br /> Art Therapist Firm 80967 American Casualty Company of Reading, Pennsylvania <br /> Excludes Cosmetic Procedures 333 S. Wabash Avenue, Chicago, IL 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 and Penalties $ 25,000 per incident $ 25,000 aggregate <br /> General Liability <br /> General Liability $1,000,000 each claim / $3,000,000 aggregate <br /> Fire &Water Legal Liability Included in the GL limit shown above subject to$250,000 aggregate sublimit <br /> Total: $2,988.00 <br /> Base Premium $2,988.00 <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-145184-A G-147292-A GSL15563 <br /> GSL15564 GSL15565 GSL17101 GSL13424 GSL13425 G-123846-C32 <br /> GSL3886 GSL3908 G-123827-B G-121487-B G-121504-C CNA79575 <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 /> Chairman of the Board Secretary to activate your coverage, please remit <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: 8/10/2015 <br />