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DocuSign Envelope ID:A83B22E2-5247-4331-8149-B62BAAA1856F <br /> HEALTHCARE PROVIDERS SERVICE <br /> CNAORGANIZATION PURCHASING GROUP <br /> (Certifitate of 311gillt'aure anso <br /> OCCURRENCE POLICY FORM Print Date: 7/12/2018 <br /> Producer Branch Prefix Policy Number Policy Period <br /> 018098 970 HPG 0651384836 from 08/15/18 to 08/15/19 at 12:01 AM Standard Time <br /> Named Insured and Address: Program Administered by: <br /> Linda E Mansmann Nurses Service Organization <br /> 8809 Farrington Mill Rd 1100 Virginia Drive, Suite 250 <br /> Chapel Hill, NC 27517-9014 Fort 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 /> Excludes Cosmetic Procedures 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 . 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 S 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 S 10,000 aggregate <br /> Assault S 25,000 per incident $25,000 aggregate <br /> Includes Workplace Violence Counseling <br /> Medical Payments S 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 $ 10,000 per incident S 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: $ 190.00 <br /> Base Premium $190,00 <br /> Premium reflects Self 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-❑ GSL10546NC G-121503-C G-121501-C G-145184-A G-147292-A GSL15563 <br /> GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G-123846-C32 <br /> CNA81753 CNA81758 CNA82011 CNA89027 CNA79575 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 /> 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 />