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HomeMy WebLinkAboutOccupational Health Centers of the Southwest - Insurance Certificatei DATE(MMlDDNYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 12/26/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poiicy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: T Concentra Unit Graham Company, PHONE ' FMarsh &McLennan Agency, LLC company .215-567-6300INC,ArNo):215-405 2694 One Penn Square West ADDRESS: Concentra Unit@grahamco.com Philadelphia PA 19102 INSURERS AFFORDING COVERAGE NAICs INSURER A:Columbia Casualty Company31127 INSURED CONCGRO-01 INSURER B: Liberty Mutual Fire Ins.Co. 23035 Occupational Health Centers of The Southwest PA dba Concentra Medical Centers INSURER C:Allied World Assurance Company,AG 5080 Spectrum Drive, Suite 1200 West iNSURERD: Employers Insurance of Wausau 21458_ Addison TX 75001 INSURER E! LM Insurance Corporation 33600 INSURER F: COVERAGES CERTIFICATE NUMBER:271006192 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - INSR AODL SUER. POLICY EFF ' POLICY EXP 1 _ LTR TYPE OF INSURANCE !IN SO WVD POLICY NUMBER MM DDrYYYY MM4)DlYYVY LIMITS A X COMMERCIAL GENERAL LIABILITY HAZ4032244581.9 1/1/2025 111/2026 EACH OCCURRENCE $1,000.000 i X AM GE TO KEN ED CLAIMS-MADE X OCCUR PREMISES(EaoccurrenceL $500,000 X Professional Lia I MED EXP(Any one person) $ 51M Claiml33M Ag PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $3.000,000 POLICY PRO LOC JECT PRODUCTS-COMP/OP AGG $3,000,000 X i i� LJ $OTHER: I B AUTOMOBILE LIABILITY i AS2-631-510199-324 j 4/1/2024 4/1/2025 COMBINED SINGLE LIMIT $2.000,000 X ANY AUTO �Ea acadenl� — --------------- --- ---.. BODILY INJURY(Per person) $ OWNED SCHEDULED ( BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident)__ _ A X I UMBRELLA LIAB X OCCUR HMC4032235752 1/1/2025 i 1/1/2026 EACH OCCURRENCE $9,000,000 EXCESS LIAB X CLAIMS-MADE AGGREGATE $10,000,000 DEC) ; X I RETENTION$ j $ B WORKERS COMPENSATION WA7-63D-510199-354 4/1/2024 4/1/2025 X i STATUTE I ERH E AND EMPLOYERS'LIABILITY Y r N WA5-63D-510199-314 1 4/1/2024 4/1/2025 ANYPROPRIETOMPARTNERJEXECUTIVE E.L.EACH ACCIDENT.— $1,000,000 OFFICERW EMBER EXCLUDED? �IN/A' _E.L.EACH ---- (Mandatory In NH) I 1 E.L.DISEASE-EA EMPLOYEE $1,000,000 II as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Property YAC-L91-477341-015 1/1/2025 111/2026 SEE BELOW C j Excess Uabiilry CO23701-0010 1/1/2025 1/1/2026 $10M Each Occurrence $10M Aggregate �I DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) PRIMARY LIABILTY POLICY includes General Liability Coverage on an Occurrence Basis and Professional Liability Coverage on a Claims Made Basis UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a$3,000,000 Self-Insured Retention each Occurrence/Claim subject to a$18,000,000 Aggregate. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244595-11: Effective 1/1/2025-1/1/2026- $500,000 Each Medical Incidentl$1,500,000 Aggregate Per Insured or Surgeon See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF FORT COLLINS ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: PURCHASING DIVISION PO BOX 580 �IO PRESENTATIVE FORT COLLILLI NS CO 80522 ,�j� /� � 01988-2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 10492: 2 ' of 3 AGENCY CUSTOMER ID: CONCGRO-01 LOC#: ACO® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 �-- AGENCY NAMED INSURED Graham Company, Occupational Health Centers of The Southwest PA dba Concentra Medical Centers POLICY NUMBER 5080 Spectrum Drive,Suite 1200 West Addison TX 75001 CARflIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244600-11; Effective 1/1/2025-1/l/2026- $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Columbia Casualty Company-Policy#HAZ 4032244614-11; Effective 1/l/2025-1/l/2026- $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244628-11; Effective 1/1/2025-1/1/2026 -$800,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Columbia Casualty Company-Policy#HAZ 4032244631-11; 1/1/2025-1/1/2026- $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244659-11; 1/1/2025-1/l/2026- $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION-Occupational Health Centers of California,A Medical Corporation-Liberty Mutual Insurance Corp.-Policy #WA5-63D-510199-314; Effective:4/l/2024-4/l/2025 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Insurance Corp.-Policy#WA7-63D-510199-404, Effective: 4/1/2024-4/1/2025 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Mutual Insurance Corp.-Policy#WC5-631-510199-254(WI); Effective:4/1/2024-4/1/2025 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas—Liberty Insurance Corp. -Policy#WC7-631-510199-284;Effective:4/1/2024-411/2025 OHC of Southwest(AZIUT)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-244; Effective:4/l/2024-4/1/2025 OHO of Delaware—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-334; Effective:4/1/20244/112025 OHO of Georgia/Hawaii—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-384; Effective: 4/1/2024-411/2025 OHC of Illinois—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-414; Effective:4/1/20244/l/2025 OHO of Louisiana—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-294; Effective:4/1/2024-4/1/2025 OHC of Michigan—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-274; Effective:4/l/2024-4/l/2025 OHC of Nebraska—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-374; Effective:4/l/2024-4/l/2025 OHC of New Jersey—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-264;Effective:4/1/2024-4/1/2025 OHC of North Carolina—Liberty Insurance Corp.-Policy#WC7-631-510199-344; Effective:4/1/2024-4/1/2025 OHC of Southwest(KS)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-424; Effective.4/1/2024-4/1/2025 Therapy Centers of Southwest I, PA(OR)-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-394; Effective:4/1/2024-4/l/2025 Therapy Centers of South Carolina, PA-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-304; Effective:4/112024-4/112025 OHC of Minnesota-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-454; Effective:4/1/2024-4/1/2025 OHC of Alaska-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-444; Effective:4/l/2024-4/112025 CYBER LIABILITY- Arch Specialty Insurance Company-Policy#NPL2001106-00,Effective. 11/2512024-11125/2025-Limit:$10,000,000 EXCESS CYBER LIABILITY-Homeland Insurance Company of New York-Policy#720002431-0000; Effective: 11125/2024-11/2512025- Limit:$10,000,000 Excess of$10,000,000 CRIME COVERAGE—National Union Fire Insurance Company of Pittsburgh, PA—Policy#02-173-18-50, Effective 11/25/2024—1/1/2026—Limit$10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured,but only for professional services performed for or on behalf of the above Named Insured. RE: OHC SWPA/CMC HAS AN AGREEMENT TO PROVIDE MEDICAL SERVICES TO THE NAMED CLIENT. CITY OF FORT COLLINS, its officers,agents and employees are all included as additional insureds on the above General Liability and Auto Liability Policies if required by written contract. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 10492: 3 - of 3