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DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNA ORGANIZATION PURCHASING GROUP MHPSO <br /> Certificate of 3lt5uranre FkAhcar,pnmdcrnS—ieel'plli_atinn- <br /> OCCURRENCE POLICY FORM Print Date: 6/02/2017 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0613252987 from 06/15/17 to 06/15/18 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Institute of Art Therapy, Inc. dba The Art Thera Healthcare Providers Service Organization <br /> Institute 159 E. County Line Road <br /> 200 N Greensboro St Ste D6 Hatboro, PA 1 9040-1 21 8 <br /> Carrboro, NC 27510-1849 1-888-288-3534 <br /> www.hpso.com <br /> Medical Specialty: Code: Insurance is provided by: <br /> Art Therapist Firm 80967 American Casualty Company of Reading, Pennsylvania <br /> Excludes Cosmetic Procedures 333 S. Wabash Avenue, Chicago, IL 60604 <br /> Professional Liability $1,000,000 each claim $ 3,000,000 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 $ 25,000 per proceeding S 25,000 aggregate <br /> Defendant Expense Benefit S 1,000 per day limit S 25,000 aggregate <br /> Deposition Representation S 10,000 per deposition '310.000 aggregate <br /> Assault S 25,000 per incident $25.000 aggregate <br /> Includes Workplace Violence Counseling <br /> Medical Payments $ 25,000 per person S 100,000 aggregate <br /> First Aid S 10,000 per incident $ 10.000 aggregate <br /> Damage to Property of Others S 10,000 per incident S 10.000 aggregate <br /> Enterprise Privacy Protection- Claims Made $ 25,000 per incident $ 25,000 aggregate <br /> Retroactive Date: 6/15/2016 <br /> (Defense inside limits) <br /> General Liability <br /> General Liability $1,000,000 each claim 1 $3,000,000 aggregate <br /> Fire &Water Legal Liability Included in the GL limit shown above subject to$250,000 aggregate sublimit <br /> Total: $3,845.00 <br /> Base Premium $3,845.00 <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-121501-C G-145184-A G-147292-A GSL15564 GSL15565 <br /> GSL17101 GSL13424 GSL13425 CNA80052 G-123846-C32 CNA81753 CNA81758 <br /> CNA82011 CNA79516NC CNA79575 G-121487-B G-121504-C G-123827-B G-123828-B <br /> Keep this document in a safe place-It <br /> f and proof of payment are your proof coverage. There is no coverage in force <br /> unless the premium is paid in hill.In order <br /> Chairman of th Board Secretary 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 /> G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: <br />