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HomeMy WebLinkAboutWorkwell Occupational Medicine, LLC dba MBI - Insurance Certificate 2025 DATE(MM/DD/YYYY) A�o® CERTIFICATE OF LIABILITY INSURANCE 12/31/2024 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 policy(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 CONTACT Donna Matz NAME: PIMS Insurance Services,LLC. A/c No Ext: (602)222-2109 AIc No): (602)200-2460 5201 N 7th Avenue E-MAIL ADDRESS: @pma dtz imsinsurance.com INSURERS AFFORDING COVERAGE NAIC H Phoenix AZ 85013-1924 INSURERA: Fidelity&Guaranty Insurance Company 35386 INSURED INSURER B: Travelers Property Casualty Company of America 25674 Workwell Occupational Medicine, LLC dba MBI INSURER C: Attn: Rachel Miller INSURERD: 1495 Garden of the Gods Road INSURER E: Colorado Springs, CO 80907 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE 'ADDLSUBRi INSD vivo POLICY NUMBER MM/D/YYYY MM DDIYYYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE IX'I OCCUR PREMISES Ea occurrence $ 1,000,000 MED EXP(Any one person) $ 10,000 A Y N BIP4P471763 01/01/2025 01/01/2026 PERSONAL&ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X ❑ POLICY PRO- C JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED AUTOS ONLY AUTOS N N BIP4P471763 01/01/2025 01/01/2026 BODILY INJURY(Per accident) S I X HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY /� AUTOS ONLY Per accident $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESSSLLIAB CLAIMS-MADE CUP4P537965 01/01/2025 01/01/2026 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 GL/EBL/Auto $ WORKERS COMPENSATION PERT LITE ER OTH- STA AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A II, �I(Mandatory in NH)_ __ _ _ ___-- _ - DISEASE=EA E If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Service Contract City of Fort Collins is included as an Additional Insured as per written contract for General Liability. Umbrella is following form. 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. Purchasing Division AUTHORIZED REPRESENTATIVE P.O. Box 580 Fort Collins CO 80522 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD