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DocuSign Envelope ID:AEC896C7-7694-41387-A4FE-8A80ADE254E5 <br /> 111HPSO c nso <br /> Healthcare Providers Service Organization- nurses service organization'" <br /> 159 East County Line Road • Hatboro,PA 19040-1218 <br /> 1.800.982-9491 •Fax 1-800-739-8818 •www.hpso.com <br /> FACSIMILE COVER FORM <br /> PLEASE DELIVER THE FOLLOWING PAGES TO: <br /> I <br /> NAME: Janice Galloway <br /> COMPANY: <br /> DATE: 06/28/17 <br /> FACSIMILE NUMBER: 919-732 -2239 <br /> FROM: Administration <br /> TELEPHONE: 800-982-9491 <br /> * IF YOU DO NOT RECEIVE ALL OF THE PAGES, OR HAVE ANY OTHER <br /> TRANSMISSION PROBLEMS, PLEASE CALL IMMEDIATELY. ; <br /> MESSAGE: <br /> NOTICE:The information contained in this message is proprietary information belonging to Affinity Insurance Services,Inc.and is intended <br /> for the personal and confidential use of the addressee. If you are not the addressee or an agent of the addressee,you are hereby notified that <br /> you have received this message in error and that any review,dissemination,distribution or copying of this message is strictly prohibited. If you <br /> have received this message in error,please notify Affinity Insurance Services immediately by telephone and return the original by mail. <br /> Dedicated To Serving The Insurance Needs of Healthcare Providers <br /> Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency; <br /> in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aun Direct Insurance Administrators <br /> License#0795465. <br />