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Producer Branch Prefix <br />018098 970 HPG <br />Named Insured and Address: <br />Melinda J Wheeler <br />Po Box 2273 <br />Los Alamitos, CA 90720 -7273 <br />HEALTHCARE PROVIDERS SERVICE <br />ORGANIZATION PURCHASING GROUP <br />Certificate of Tottrance <br />OCCURENCE POLICY FORM <br />Policy Number <br />0583424467 <br />Medical Specialty: Code: <br />Pediatric /Neonatal /Fam Practice Nurse Practit 80965 <br />Print Date: 4/14/2014 <br />mnso i <br />Policy Period <br />from 02/13/14 to 02113/15 at 12:01 AM Standard Time <br />Program Administered by: <br />Nurses Service Organization <br />159 E. County Line Road <br />Hatboro, PA 1 9040 -1 21 8 <br />1- 800 -247 -1500 <br />www. nso. com <br />Insurance is provided by: <br />American Casualty Company of Reading, Pennsylvania <br />333 S. Wabash Avenue, Chicago, IL 60604 <br />Excludes Cosmetic Procedures <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 <br />Defendant Expense Benefit <br />Deposition Representation <br />Assault <br />Includes Workplace Violence Counseling <br />Medical Payments <br />First Aid <br />Damage to Property of Others <br />Information Privacy (HIPAA) Fines and Penalties <br />Workplace Liability <br />Workplace Liability <br />Fire & Water Legal Liability <br />Personal Liability <br />Total: 3 1,133.00 <br />Base Premium $1,133.00 <br />$ 25,000 <br />per proceeding <br />$ 25,000 <br />aggregate <br />$ 1,000 <br />per day limit <br />$ 25,000 <br />aggregate <br />$ 10,000 <br />per deposition <br />$ 10,000 <br />aggregate <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />$ 25,000 <br />per person <br />$ 100,000 <br />aggregate <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />$ 10,000 <br />per incident <br />$ 10,000 <br />aggregate <br />$ 25,000 <br />per incident <br />$ 25,000 <br />aggregate <br />Included in Professional Liability Limit shown above <br />Included in the PL limit shown above subject to $150,000 aggregate sublimit <br />$1,000,000 aggregate ORM <br />- :Kn,irlft� YI, <br />Premium reflects Self Employed , Full Time <br />1,aura A. Rossini <br />A.5istant City [Attorney <br />Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and <br />endorsements.) <br />G- 121500 -D G- 121503 -0 <br />GSL15564 GSL15565 <br />GSL3908 GSL19904 <br />G- 121501 -C1 G- 145184 -A <br />GSL17101 GSL13424 <br />G- 147292 -A GSL15563 <br />G- 123846 -D04 GSL3886 <br />Keep this document in a safe place. It <br />and proof of payment are your proof <br />coverage. There is no coverage in force <br />unless the premium is paid in full. In order <br />Chairman of the Board Secretary to activate your coverage, please remit <br />emium in full b the effective date of <br />V <br />Y <br />this Certificate of Insurance. <br />Master Policy # 188711433 <br />G- 141241 -B (03/2010) Coverage Change Date: Endorsement Change Date: <br />