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DocuSign Envelope ID: 51596CFA- 3841 -4DE4- 9245- D1D4F2A965C1 <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROUP <br />CNA rm <br />Catifirate of 31tvatra ace anso <br />nurses serviceorpinizallon <br />OCCURRENCE POLICY FORM Print Rate: 08/22117 <br />PRODUCER BRANCH PREFIX I POLICY NUMBER <br />018098 970 HPG 0003508294 -8 <br />Named Insured <br />Linda K Textoris <br />754 Weaver Dairy Rd Apt 204 <br />Chapel Hill, NC 27514 -1466 <br />Medical Specialty Code <br />Registered Nurse 80954 <br />Policy Period: <br />From 09108117 to 09/08118 at 12:01 AM Standard Time <br />Program Administered by: <br />Nurses Service Organization <br />159 E. County Line Road <br />Hatboro, PA 19040 -1218 <br />1 -800- 247 -1500 <br />www.nso.com /renew <br />Insurance is provided by:._ <br />American Casualty Company of Reading, Pennsylvania <br />333 South Wabash Avenue Chicago, Illinois 60504 <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 $25,000 aggregate sublimit <br />Coverage Extensions <br />License Protection <br />$ 25,000 per proceeding <br />$ <br />25,000 <br />aggregate <br />Defendant Expense Benefit <br />$ 1,000 per day limit <br />$ <br />25,000 <br />aggregate <br />Deposition Representation <br />$ 10,000 per deposition <br />$ <br />10,000 <br />aggregate <br />Assault <br />$ 25,000 per incident <br />$ <br />25,000 <br />aggregate <br />Precludes Workplace violence Counseling <br />Medical Payments <br />$ 25,000 per person <br />$ <br />100,000 <br />aggregate <br />First Aid <br />$ 10,000 per incident <br />$ <br />10,000 <br />aggregate <br />Damage to Property of Others <br />$ 10,000 per incident <br />$ <br />10,000 <br />aggregate <br />Information Privacy (HIPAA) Fines & Penalties $ 25,000 per incident <br />$ <br />25,000 <br />aggregate <br />Workplace Liability <br />Workplace Liability <br />Included in Professional Liability Limit shown above <br />Fire and Water Legal Liability <br />Included in the PL limit above subject to $150,000 aggregate sublimit <br />Personal Liability <br />$1,000,000 aggregate <br />Total: $106.00 <br />Premium reflects employed, full -time rate. <br />Policy Forms $ Endorsements (Please see attached list for a general description of many common policy forms and endorsements.) <br />G- 121500 -D G- 121501 -C G- 121503 -C GNA82011 G- 145184 -A G- 147292 -A CNA81753 CNA81758 GSL13424 GSL15563 <br />GSLIS564 GSL16565 GSL17101 CNA80052 CNA80051 G- 123846 -C32 GSL10546NC <br />I <br />Chairman of the Board <br />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 -13 (312010) <br />NSO- 405- N-NUB -N1 20170822 -006 <br />Master Policy: 188711433 <br />