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DocuSign Envelope ID:442C35DB-8F7E-464D-90B8-19DA4AF12B4F <br /> I <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNAORGANIZATION Certificate of �1>��ur�lrrce GROUP onso <br /> nurses service organization', <br /> OCCURENCE POLICY FORM Print Date: 11/18/2015 <br /> i <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0596951183 from 10/01/15to 10/01/16 at 12:01 AM Standard Time <br /> r <br /> Named Insured and Address: Program Administered by: <br /> Janet Whitesides Nurses Service Organization 4 <br /> 107 Center St 159 E. County Line Road <br /> Carrboro, NC 27510-1735 Hatboro, PA 19040-1218 <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 /> I <br /> Professional Liability $ 500,000 each claim $2,500,000 aggregate I <br /> i <br /> Your professional liability limits shown above include the following: <br /> • Good Samaritan Liability Malplacement Liability * Personal Injury Liability F <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 f <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 $500,000 aggregate <br /> Total:$ 88.00 <br /> Base Premium $88.00 <br /> i <br /> Premium reflects Employed , Part Time <br /> i' <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-121503-C G-121501-C G-145184-A G-147292-A <br /> GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 <br /> CNA80052 G-123846-C32 CNA81753 CNA81758 <br /> Keep this document in a safe place.lt <br /> ^ I and proof of payment are your proof of <br /> cc. ti.1L I"Sec � coverage. There is no coverage in force <br /> unless the premium is paid in full.In order <br /> Chairman of the Board r 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: <br /> it <br />