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DocuSign Envelope ID: CBBE423A-9D53-4533-93A1-4DAB6416895F <br /> HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> cNA <br /> Certificate of , rtguraucc mnso <br /> nurses service organization <br /> OCCURRENCE POLICY FORM <br /> PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0274154966-0 From 11/18/15 to 11/18/16 at 12:01 AM Standard Time <br /> Named Insured Program Administered by: <br /> Nurses Service Organization A <br /> Stephanie Anne Yost 159 E. County Line Road <br /> 7700 Amesbury Dr Hatboro, PA 1 9040-1 21 8 <br /> Chapel Hill, NC 27514-9713 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 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 /> o Good Samaritan Liability e Malplacement Liability ® Personal Injury Liability <br /> o Sexual Misconduct included in the PL Limit shown above subject to$25,000 aggregate sublimit is <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 CNA82011 G-145184-A G-147292-A CNA81753 CNA81758 GSL13424 GSL15563 <br /> GSL15564 GSL15565 GSL17101 CNA80052 CNA80051 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 />