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DocuSign Envelope ID: 2AC19FOC- 9E3C- 4689- A96A- CCF2OD2FFB98 <br />HEALTHCARE PROVIDERS SERVICE <br />CNAORGANIZATION PURCHASING GROUP <br />Certificate of lit5uranre onso <br />OCCURRENCE POLICY FORM Print Date: 6/28/2018 <br />Producer Branch Prefix Policy Number Policy Period <br />018098 970 HPG 0647224005 from 07/01/18 to 07/01/19 at 12:01 AM Standard Time <br />Named Insured and Address: <br />Katrice A Hester <br />6049 -a Pinetown Rd <br />Oxford, NC 27565 -7956 <br />Medical Specialty: <br />Registered Nurse <br />Program Administered by: <br />Nurses Service Organization <br />1100 Virginia Drive, Suite 280 <br />Fort Washington, PA 19034 <br />1- 800 -247 -1500 <br />www.nso.com <br />Code: Insurance is provided by: <br />80964 American Casualty Company of Reading, Pennsylvania <br />333 S. Wabash Avenue, Chicago, IL 60604 <br />Professional Liability <br />$1,000,000 each claim $ 6,000,000 <br />aggregate <br />Your professional liability limits shown above include the following: <br />• Good Samaritan Liability <br />* Malplacement Liability 'Personal Injury Liability <br />• Sexual Misconduct Included <br />in the PL limit shown above subject to $ 25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />S25,000 per proceeding S 25;000 <br />aggregate <br />Defendant Expense Benefit <br />S1,000 per day limit S 25,000 <br />aggregate <br />Deposition Representation <br />S10,000 per deposition S 10;000 <br />aggregate <br />Assault <br />S25,000 per incident $25,000 <br />aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments <br />S25,000 per person S1001000 <br />aggregate <br />First Aid <br />S10,000 per incident $10,000 <br />aggregate <br />Damage to Property of Others <br />S10,000 per incident S10.000 <br />aggregate <br />Information Privacy (HIPAA) Fines <br />and Penalties S25,000 per incident $25.000 <br />aggregate <br />Media Expense <br />$ 25,000 per incident $ 25,000 <br />aggregate <br />Workplace Liability <br />Workplace Liability <br />Included in Professional Liability Limit shown above <br />Fire & Water Legal Liability <br />Included in the PL limit shown above subject to $150,000 aggregate sublimit <br />Personal Liability <br />$1,000,000 aggregate <br />Total: $ 106.00 <br />Base Premium $106.00 <br />Premium reflects Employed , Part Time <br />Policy Forms & Endo rsements(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-1 47292-A GSL15563 <br />GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G- 123846 -C32 <br />CNA81753 CNA81758 CNA82011 <br />Chairman of th Board <br />CNA89027 CNA89026 <br />Secretary <br />G- 141241 -13 (03/2010) Coverage Change Date <br />Keep this document in a safe place- It <br />and proof of payment are your proof of <br />coverage. There is no coverage in force <br />unless the premium is paid in full. In order <br />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 />Endorsement Change Date: <br />