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DocuSign Envelope ID:E9EF5F09-83C7-48AB-B736-FC3D8CO2309A
<br /> HEALTHCARE PROVO*,E",S SER'10E
<br /> . ORGANOZATI•N PURCHASONG GROUP
<br /> tm: k -44'I ,,,,- Certificate of Novara 1,2, , nsu
<br /> ,,,, ,,v ,,_,,
<br /> nurses service organization
<br /> OCCURRENCE POLICY FORM
<br /> PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period:
<br /> 018098 I 970 HPG J ;03:12115639-8 From 03/27/16 to 03/27/17 at 12:01 AM Standard Time
<br /> Named Insured ;, Program Administered by:
<br /> `' . Nurses Service Organization
<br /> rJanice Galloway 159 E. County Line Road
<br /> 6615 Glen Forrest - ;Yy.
<br /> x. Hatboro, PA 19040-1218
<br /> pel Hill, NC 17-8631 1-800-247-1500
<br /> '.. . z;' ' www.nso.com
<br /> Medical Specialty u: Code Insurance is provided by:
<br /> Registered Nurse ,• _, a' l'' 80964 American Casualty Company of Reading,Pennsylvania
<br /> .1''7 ." ,_0 333 South Wabash Avenue Chicago, Illinois 60604
<br /> `5s '�. 9
<br /> Professional Liability 14 (.; ' $1,000,000 each claim $6,000,000 aggregate
<br /> Your professional liability limits shown above inclutle the following:
<br /> o Good Samaritan Liability' o Malplacement Liability o Personal Injury Liability
<br /> o Sexual Misconduct ig Gdedin,tl e PL Limit shown above subject to$25,000 aggregate sublimit
<br /> it
<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 0-121501-C G-121503-C CNA82011 G-145184-A G-147292-A CNA81753 CNA81758 GSL13424 GSL15563
<br /> GSL15564 GSL15565 GSL17101 CNA80052 CNA80051 0-123846-C32 GSL10546NC
<br /> ' i ,. L4
<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#:0-141241-B(3/2010) Master Policy: 188711433
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