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DocuSign Envelope ID: 12D4206E-0D82-4E82-BF44-D5FD9591 E67C <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNA ORGANIZATION PURCHASING GROUP onso <br /> Certificate of In5ur since <br /> nurses service organization- <br /> OCCURRENCE POLICY FORM Print Date: 7/02/2016 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0618039403 from 05/27/16 to 05/27/17 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Karah A Daniel Nurses Service Organization <br /> 70 Southern Green Way 159 E. County Line Road <br /> Chapel Hill, NC 27517-9311 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 /> Professional Liability $1,000,000 each claim $6,000,000 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 /> 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 $1,000,000 aggregate <br /> Total: $ 106.00 <br /> Base Premium $106.00 <br /> Premium reflects Employed , Full Time <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 CNA82011 <br /> Keep this document in a safe place.lt k' <br /> Vuerw-4 /'''� � and proof of payment are your proof of f, <br /> �,L 1 .� IA <br /> 7k4- co e is unless the premium is paid in full.ln orderI <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: <br />