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DocuSign Envelope ID:494289F0-8E30-4C81-84B3-99B39200A68F <br /> HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> VA Ctrtiticatt of 3inatrance mnso <br /> nurse service CTr}jY1uz itr[Tn <br /> OCCURRENCE POLICY FORM <br /> PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 ❑❑❑ 0617869543-8 From 04/22/16 to 04/22/17 at 12:01 DM❑tandard Lime <br /> Named Insured Program Administered by: <br /> ❑urses Dervice Organization <br /> Jennifer ❑ugg 159 O. ❑ounty Line Doad <br /> al Box 272 Datboro, D❑ 19040-1218 <br /> Bynum, ❑❑ 27228-0272 1-800-247-1500 <br /> www.nso.com <br /> Medical Specialty Code Insurance is provided by: <br /> Degistered Durse 80964 [7merican Dasualty Dompany of Leading, Dennsylvania <br /> 333 Louth Wabash Dvenue Dhicago, Minois 60604 <br /> Professional Liability $1,000,000 each claim $6,000,000 aggregate <br /> Your professional liability limits shown above include the following: <br /> • Dood ❑amaritan Liability • Malplacement ❑ability • Dersonal Ilijuty Liability <br /> • ❑exualMisconduct included in the ❑D Limit shown above subject to $25,000 aggregate sublimit <br /> Coverage Extensions <br /> License Drotection $ 25,000 per proceeding $ 25,000 aggregate <br /> Defendant Dlxpense Benefit $ 1,000 per day limit $ 25,000 aggregate <br /> Deposition Representation $ 10,000 per deposition $ 10,000 aggregate <br /> Dssault $ 25,000 per incident $ 25,000 aggregate <br /> un IEJECIO MO=OMB=0 DEIDEILIM <br /> Medical Dayments $ 25,000 per person $ 100,000 aggregate <br /> First Did $ 10,000 per incident $ 10,000 aggregate <br /> Damage to Droperty of Others $ 10,000 per incident $ 10,000 aggregate <br /> information Orivacy(DHDD)Fuses &Denalties $ 25,000 per incident $ 25,000 aggregate <br /> ❑ DLLDH❑❑LHMI] <br /> Workplace Liability [deluded nr Drofessional Liability Limit shown above <br /> Fire and Water Llsgal Liability Idcluded in the ❑❑limit above subject to$150,000 aggregate sublimit <br /> Dersonal Liability $1,000,000 aggregate <br /> T O®HL1111 <br /> PEED H❑ =EOM❑D OHLD❑❑®MIMB ❑CD®❑ <br /> Policy Forms &Endorsements Pease see attached list fora general description of many common policyfonns and endorsements.; <br /> D-121500-0 D-121501-D ❑-121503-0 D11082011 11-145184-0 0-147292-0 DO 081753 0❑081758 0 001342 00015563 <br /> DDD15564 ❑1215565 D❑017101 D 0080052 0❑080051 0-123846-032 0 0010546D <br /> V441%40'44 ("0. ,,,A4/1A1M14--A. <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 #: D-141241-B(3/2010) Master Dolicy: 188711433 <br /> rrmainoln ranarrrrri= <br />