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DocuSign Envelope ID: F02746BF- D92E- 42E9- ACB1- 079917CF5B3E <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROUP <br />CNA Cerfif icate of Junwance <br />OCCURRENCE POLICY FORM <br />PRODUCER BRANCH PREFIX POLICY NUMBER <br />018098 970 HPG 0617869543 -8 <br />Named Insured <br />Jennifer Sugg <br />PO Box 272 <br />Bynum, NC 27228 -0272 <br />Medical Specialty Code <br />Registered Nurse 80964 j <br />onso <br />nurses service orpanizition <br />Print Date: 04/20/18 <br />Policy Period: <br />From 04/22118 to 04/22/19 at 12:01 AM Standard Time <br />Program Administered by: <br />Nurses Service Organization <br />1100 Virginia Drive, Suite 250 <br />Fort Washington, PA 19034.3278 <br />1 -800 -247 -1500 <br />www.nso.com /renew <br />Insurance is provided by: <br />American Casualty Company of Reacting, Pennsylvania. <br />333 South Wabash Avenue Chicago, Illinois 60604 <br />Professlonol Liability <br />$1,000 „000 each claim <br />$6,000,000 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 in the PL Limit shown above subject to $25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />$ <br />25,000 per proceeding <br />$ <br />25,000 <br />aggregate <br />Defendant Expense Benefit <br />$ <br />1,000 per clay limit <br />$ <br />25,000 <br />aggregate <br />Deposition Representation <br />$ <br />10,000 per deposition <br />$ <br />10,000 <br />aggregate <br />Assault <br />$ <br />25,000 per incident <br />$ <br />25,000 <br />aggregate <br />Includes Workplace Violence Counseling <br />Medical Payments <br />$ <br />25,000 per person <br />$ <br />100,000 <br />aggregate <br />First Aid <br />$ <br />10,004 per incident <br />$ <br />14,000 <br />aggregate <br />Damage to Property of Others <br />$ <br />10,000 per incident <br />$ <br />10,000 <br />aggregate <br />Information Privacy (HIPAA) Fines & Penalties <br />$ <br />25,000 per incident <br />$ <br />25,000 <br />aggregate <br />Workplace Liability <br />Workplace Liability Included in Professional Liability Limit shown above <br />Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sublimit <br />Personal Liability $1,000,000 aggregate <br />Total: $106.00 <br />Premium reflects employed, full -time rate. <br />Policy Forms & Endorsements (Please see attached list fora general description of many common policy forms and endorsements.) <br />G- 121500 -1) G- 121501 -C G- 121503 -C CNA82011 G- 145184 -A G- 147292 -A CNA81753 CNA81758 GSL13424 GSL15563 <br />GSL15564 GSL15565 GSL17101 CNA84052 CNA80051 G- 123846 -C32 GSL10546NC <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 #: G- 141241 -B (3/2010) Master Policy: 188711433 <br />100 - 2WRAUR -H1 201004M006 <br />