HEALTHCARE PROVIDERS SERVICE

ORGANIZATION PURCHASING GROUP

018098 970 HPG 0644087264-8 From 10/03/16 to 10/03/17 at 12:01 AM Standard Time Guerda Bien-Aime

***** ***** *** ** *

Jamaica, NY 11434-5910

Nurses Service Organization

159 E. County Line Road

Hatboro, PA 19040-1218

1-800-***-****

www.nso.com

American Casualty Company of Reading, Pennsylvania 333 South Wabash Avenue Chicago, Illinois 60604

$1,000,000 each claim $3,000,000 aggregate

Your professional liability limits shown above include the following:

• Good Samaritan Liability • Malplacement Liability • Personal Injury Liability

• Indirect Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sublimit License Protection

Defendant Expense Benefit

Deposition Representation

Assault

Includes Workplace Violence Counseling

Medical Payments

First Aid

Damage to Property of Others

Information Privacy (HIPAA)

Workplace Liability Included in Professional Liability Limit shown above Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate

Total: $27.00

(Please see attached list for a general description of many common policy forms and endorsements.) G-121500-D G-121501-C G-121503-C CNA82011 G-145184-A G-147292-A CNA81753 CNA81758 GSL13424 CNA80052 CNA80051 G-123846-D31 G-123813-C31 GSL10550NY GSL11892NY GSL15563NY GSL18064NY GSL15565NY GSL17101

Form #: G-141241-B31 (3/2010) Master Policy: 188711433 Premium reflects employed, full-time rate with recent graduate discount. NSO-602-N-NUR-N1 201*****-***

$

$

$

$

$

$

$

$

25,000

1,000

10,000

25,000

25,000

10,000

10,000

25,000

$

$

$

$

$

$

$

$

per proceeding

per day limit

per deposition

per incident

per person

per incident

per incident

per incident

25,000

25,000

10,000

25,000

100,000

10,000

10,000

25,000

aggregate

aggregate

aggregate

aggregate

aggregate

aggregate

aggregate

aggregate

Nursing Assistant

Workplace Liability

80963

POLICY FORMS & ENDORSEMENTS

The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. State specific policy forms and endorsements are not included in the list below. Should you require descriptions or samples of these documents, please visit us online at www.nso.com/policyforms. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. All products and services may not be available in all states and may be subject to change without notice. Think Green – expanded definitions and copies of these policy forms and endorsements are available online at www.nso.com/policyforms. COMMON POLICY FORMS & ENDORSEMENTS

FORM # DESCRIPTION

G-121500-D Common Policy Conditions

G-121501-C Occurrence Policy Form

G-121503-C Workplace Liability Form

CNA82011 Healthcare Providers Related Claims Endorsement G-145184-A Policyholder Notice - OFAC Compliance Notice G-147292-A Policyholder Notice - Silica Mold & Asbestos Disclosure CNA81753 Cap on Losses from Certified Acts of Terrorism CNA81758 Offer of Terrorism Coverage - Disclosure of Premium GSL13424 Services to Animals

CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement CNA80051 Amended Definition of Personal Injury Endorsement G-123846-D31 New York Cancellation and Non-Renewal G-123813-C31 New York Amendatory Change Endorsement GSL10550NY New York Amendatory Endorsement

GSL11892NY New York Amendatory Endorsement

GSL15563NY Information Privacy Coverage Endorsement HIPAA Fines - New York GSL18064NY New York Amendatory Change Endorsement

GSL15565NY Healthcare Providers Professional Liability Assault Coverage - New York GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD.

Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner’s status change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Nurses Service Organization for details.

Form #: G-141241-B31

Master Policy #: 188711433

Named Insured: Guerda Bien-Aime

Policy #: 0644087264-8

N10412

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