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r AV/ <br />i <br />Woducef E raFICII Prefix <br />018098 970 F1 PG <br />Named Insured and A(Jd re.s : <br />S l f3dlhasiie Anne Yost <br />7700 Arnesbuiry Dr <br />Chapel I-- 11. NC 27514 -971 <br />Medical Specialty: <br />Registered Nurse <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROLJP <br />OCCURRENCE POLICr Y FORM <br />0274154966 from 11 /1 all to I I <br />iNTISO <br />print Dale' 1112017 <br />Program Adrninim red t) <br />NUrSeS Service r aniZa'� 0 <br />Halbom 0 PA 19040-1219 <br />1-800-247-1500 <br />Code: Insufance is provided by* <br />S. Wabash Avenue, Chicago, IL 60604 <br />Professional Liability $1, 000, 000 each claim S .C)00, ,000 aggregate <br />Your Professional liability limits shown above include the following'. <br />Good Samaritan Llability Malplacement Liability Of per T -La1 t*ry Liability <br />Sexual Misconduct ondu III tud d in the ILL limit shown above subj to ,000 aggregate �ibl' mil <br />Coverage Extensions <br />License Protection $25,000 <br />Defendant Expense Benefit $1,000 <br />Deposition Representation S 10,000 <br />Assault 251000 <br />1 n ludes Wo rkplace V i olle nce Cou selin 9 25,000 <br />l'e.1cal Pant s 1,000 <br />First Aid $10,000 <br />Damage to Property of Other ,0 <br />Info,rmation Privacy (HI ) Fines r� ;F r� lt�. <br />W,Drkplace Liability <br />Workpiace Liability <br />Fire & Water Legal Liability <br />personal Lability <br />I�rt <br />-% <br />Base PremiuM 106,00 <br />pef proceeding <br />per day 1ymil <br />per deposition <br />per incident <br />per p tS" On <br />per incident <br />per incident <br />per inciderft <br />25,000 <br />25,,000 <br />$10,000 <br />25,000 <br />$100,000 <br />l ri d in professional Liability Li Mi ShO 11 above $150.000 <br />included in the PL iirnit S o n a <br />1 , 000 ,000 aggregate <br />crate <br />arse <br />a "ret <br />aggregate <br />aggregate <br />agtek <br />a gT zt <br />Fuil Time <br />Prey Ernployed ti of n o � n policy f rr>� and <br />see attached list for a general dry <br />Policy Forms & Endorseme 1 565 <br />Chairman f th <br />G- 141241 -8 (03/2010) <br />G�l 503-C <br />GSL1 7101 <br />01 1 <br />Gi 1 501 s <br />LI <br />cove rag h n. Dale: <br />t <br />-I-t <br />col <br />0 G-123846-C32 <br />Keep this docurnent in a SatO PlacO, It <br />� <br />,�& r your Droof <br />and prowl o r ,�ay,,,W,.» ... _ , -- <br />coverage. There Is no coverage �n force <br />unJess the prem,um is ,yard in full In order <br />nn,roYal7R e r e reM-i` <br />to activate you, CON , - <br />prernium in full thO effective date of <br />j f ,s Cim,,rtif�cate of insurance <br />Moister PoliCLY # I BB711433 <br />Endorsement Change Date' . <br />0 <br />0 <br />n <br />c <br />M <br />m <br />