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DocuSign Envelope ID:74F011EB-23A7-4767-91C1-8E4C25122630 <br /> HEALTHCARE PROVIDERS SERVICE <br /> ORGANIZATION PURCHASING GROUP <br /> CNA (ert[ftcate of 31morance 0HPS0 <br /> OCCURRENCE POLICY FORM Print Date: 07/09/18 <br /> PRODUCER BRANCH PREFIX POLICY NUMBER Policy Period: <br /> 018098 970 HPG 0273935164-8 From 07/27/18 to 07/27/19 at 12:01 AM Standard Time <br /> Named Insured Prouram Administered by: <br /> Healthcare Providers Service Organization <br /> Charron F Andrews 1100 Virginia Drive, Suite 250 <br /> 108 Cottonwood Ct Fort Washington, PA 19034-3278 <br /> Chapel Hill, NC 27514-1629 1-800-982-9491 <br /> www.hpso.com/renew <br /> Medical Specialty Code Insurance is provided by: <br /> Physical Therapist 80995 American Casualty Company of Reading, Pennsylvania <br /> 333 South Wabash Avenue Chicago, Illinois 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 $ 25,000 aggregate <br /> Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate <br /> Deposition Representation $ 10,000 per deposition $ 10,000 aggregate <br /> Assault $ 25,000 per incident $ 25,000 aggregate <br /> Includes Workplace Violence Counseling <br /> Medical Payments $ 25,000 per person $ 100,000 aggregate <br /> First Aid $ 10,000 per incident $ 10,000 aggregate <br /> Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate <br /> Information Privacy(HIPAA) Fines&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 and Water Legal Liability Included in the PL limit above subject to$150,000 aggregate sublimit <br /> Personal Liability $1,000,000 aggregate <br /> Total:$157.00 <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 CNA82011 G-145184-A G-147292-A CNA81753 CNA81758 GSL13424 GSL15563 <br /> GSL15564 GSL15565 GSL17101 CNA80052 CNA80051 G-123846-C32 GSL10546NC CNA89026 CNA89026 CNA89027 <br /> Chairman of the Board 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-B(3/2010) Master Policy: 188711433 <br /> HPSO-405-13-PHY-H1 20180709-005 <br />