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DocuSign Envelope ID:AEE4F3FE-D5B5-42A5-8AE4-F57FB7BA7945 <br /> HEALTHCARE PROVIDERS SERVICE <br /> ������AN�AT|��NPUF&CHAS|N�� ��R��UP <br /> Cr NA Certificate of c�VK5ttr��UVce ~` nso <br /> nurses service organization <br /> OCCURRENCE POLICY FORM Print Date: 7/02/2017 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0647224005 from 07/01/17 to 07/01/18 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Katrice A Hester Nurses Service Organization <br /> 6049-a Pinetown Rd 159 E. County Line Road <br /> Oxford, NC 27666-7966 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 $8.0U0.80O aggregate <br /> Your professional liability limits shown above include the following: <br /> * Good Samaritan Liability * K8a|p|encment 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 $ 10U.U0U aggregate <br /> First Aid $ 1O.00O per incident $ 10,000 aggregate <br /> Damage to Property of Others $ 10,000 per incident $ 1O.0OO 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 . Part 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'121603-C G421501'C G446184-A G'147292-4 GSL15563 <br /> G8L15564 {SSL15666 G8L171O1 GSL13424 CNA80051 CNA80062 {S-123846-C32 <br /> CNA81753 CNA81758 CNA82O11 <br /> Koep this document in a safo place.It <br /> C6444/v 7,I ° ~ and proof ofpayment are your proof of <br /> coverage. coverage n force un/eoabhepnemiumispaidin8/nome <br /> r <br /> to activate your coverage please remit <br /> Chairman nfth" Board <br /> Secretary premium in full by the effective date of <br /> this Certificate of Insurance. <br /> Master Poli #188711438 <br /> G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: <br />