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DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 <br /> HEALTHCARE PROVIDERS SERVICE <br /> 4 tiVA ORGANIZATION PURCHASING GROUP <br /> eetttft <br /> to of 3ti urante onso <br /> nurses service organization- <br /> OCCURRENCE POLICY FORM Print Date: 6/28/2017 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0312115639 from 03/27/17 to 03/27/18 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Janice Galloway Nurses Service Organization <br /> 6615 Glen Forrest Dr 159 E. County Line Road <br /> Chapel Hill, NC 27517-8631 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 /> 25 000 per incident 25 000 aggregate <br /> Information Privacy(HIPAA) Fines and Penalties $ p $ <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 GSL15563 <br /> GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G-123846-C32 <br /> CNA81753 CNA81758 CNA82011 <br /> Keep this document in a safe place.tt <br /> , C641/41/2 �1„V <br /> v l f and proof of payment are your proof of <br /> coverage. There is no coverage in force <br /> unless the premium is paid in ful.In order <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 />