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DocuSign Envelope ID:CF846751-E6B1-4B2E-BD71-5008930BB362 <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNAORGANIZATION PURCHASING GROUP <br /> Certificate of 11wuranre <br /> ansoo <br /> OCCURRENCE POLICY FORM Print Date: 5/13/2019 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0678249468 from 06/01/19 to 06/01/20 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Jennifer Ginsburg Nurses Service Organization <br /> 215 Boulder Bluff Trl 1100 Virginia Drive, Suite 250 <br /> Chapel Hill, NC 27516-9657 Fart Washington, PA 19034 <br /> 1-800-247-1500 <br /> www.nso.com <br /> Medical Specialty: Code: insurance is provided by: <br /> Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania <br /> 333 S. Wabash Avenue, Chicago, IL 60604 <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 W 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 $25,000 aggregate <br /> Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate <br /> Deposition Representation $ 10,OOiD per deposition S 10,000 aggregate <br /> Assault $ 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 $ 10,000 per incident $10,000 aggregate <br /> [Damage to Property of Others $ 10,D00 per incident $10,000 aggregate <br /> Information Privacy(HIPAA) Fines and Penalties $ 25,000 per incident $25,000 aggregate <br /> Media Expense $ 25,000 per incident $ 25,000 aggregate <br /> Workplace Liability <br /> Workplace Liability Included in Professional Liability Limit shown above <br /> Fire &Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit <br /> Personal Liability $1,000,000 aggregate <br /> Total: $ 106.00 <br /> Base Premium $106.00 <br /> Premium reflects Employed , Part Time <br /> Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and <br /> endorsements.) <br /> G-121500-D GSL10545NC G-121503-C G-121501-C G-145184-A G-147292-A GSL15563 <br /> GSL15564 GSL16565 GSL17101 GSL13424 CNA80051 CNA80052 G-123846-C32 <br /> GNA81753 CNA81758 CNA82011 CNA89027 CNA89026 <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 /> Chairmanâť‘f 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 />