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HomeMy WebLinkAboutConcentra Medical Centers - Insurance Certificatei DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE FDATE DN 025 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 endorsements). PRODUCER UUNNAME C Concentra Unit Graham Company, PHONE 215 567-6300 ac No):215-405-2694 a Marsh & McLennan Agency, LLC company E-MAIL 30 S 15th Street, 20th Floor ADDRESS: Concentra-Unit@grahamco.com Philadelphia PA 19102 INSURER(b)AFFORDING COVERAGE NAICtI INSURER A:Columbia Casualty Company 31127 INSURED CONCGRO-01 INSURER B: Liberty Mutual Fire Ins.Co. 23035 Occupational Health Centers of The Southwest PA dba Concentra Medical Centers INsuRERc:Allied World Assurance Company,AG 5080 Spectrum Drive, Suite 1200 West wsugERD: Employers Insurance of Wausau _ —_ 21458 Addison TX 75001 INSURER E: LM Insurance Corporation 33600 INSURERF: Liberty Insurance Corporation 42404 COVERAGES CERTIFICATE NUMBER:1636011070 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 ADOL!SUBpi POLICYEFF L_0OLICYEXP LTR TYPEOFINSURANCE IN D WVDI POLICY NUMBER MM/DD/YYVY MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y HAZ4032244581-9 1/1/2025 1/1/2026 EACH OCCURRENCE $1.000.000 �'. AMA E TiD RENTE CLAIMS-MADE X OCCUR PREMISgs aoocurrenoe $500,000 X Professional Lia MED EXP(Any one person) $ X $7M Claim1$3M Ag PERSONAL&ADV INJURY $1.000,000 i GEN'L AGGREGATE LIMIT APPLIES PER 1 GENERAL AGGREGATE $3,000,000 X� POLICY PRO- JECTLOC PRODUCTS-COMP/OP AGG $3,000,000 — OTHER: $ B AUTOMOBILE LIABILITY Y AS2-631-510199-325 4/112025 4/1/2026 COMBINED SINGLE LIMIT $2.000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE HIRED IHI NON-OWNED I AUTOS ONLY AUTOS ONLY �(Per accident $ $ A X UMBRELLA LIAB X . 00CUR y HMC4032235752 1/1/2025 1/1/2026 EACHOCCURRENCE $9,000,000 EXCESS LtA6 X 1 CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$ $ E WORKERAND S COMPENSATION WA7-63D-510199-355 j 4/1/2025 4/1/2026 IX PE STATUTE ERH YIN WA5-63D-510199.315 4/1/2025 4/1/2026 —1 ANYPROPRIETOR;PARTNERIEXECUTIVE EL.EACH ACCIDENT $1,000,000 OFFICER/M EMBER EXCLUDED? N I A i---- ------------- -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D !Property YAC-L9L-477341-015 i 111/2025 111/2026 :SEE BELOW C Excess LiabilityCO23701/010 1/1/2025 1/1/2026 $10M Each Occurrence $10M Aggregate I I DESCRIPTION OF OPERATIONS I 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/l/2026- $500,000 Each Medical Incident/$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. PO BOX 580 PURCHASING DIRECTOR AUTro 77PRESENTATIVE FORT y FORT COLLINS CO 80522 � .� i 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 10794: 2 ' of 3 AGENCY CUSTOMER ID: CONCGRO-01 �--, LOC#: .41 0/ZI7® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Graham Company, NAMED INSURED Occupational Health Centers of The Southwest PA POLICY NUMBER dba Concentra Medical Centers 5080 Spectrum Drive, Suite 1200 West Addison TX 75001 CARflIER NAIL 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 403224460051, Effective 1/1/2025 1/1/2026 $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 1/112025-1/112026- $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/l/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/l/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-510199-315; Effective:4/l/2025-4/1/2026 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Insurance Corp. -Policy#WA7 63D 510199 405; Effective: 4/l/2025-411/2026 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Mutual Insurance Corp.-Policy#WC5-631-510199-255(WI); Effective:4/l/2025-4/l/2026 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas—Liberty Insurance Corp. -Policy#WC7-631-510199-285; Effective:4/l/2025-4/l/2026 OHC of Southwest(AZ/UT)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-245; Effective:4/1/2025-4/l/2026 OHC of Delaware—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-335; Effective:4/l/2025-4/l/2026 OHC of Georgia/Hawaii--Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-385; Effective: 411/2025-411/2026 OHC of Illinois—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-415; Effective:4/l/2025-4/l/2026 OHC of Louisiana—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-295; Effective:4/l/2025-4/1/2026 OHC of Michigan—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-275; Effective:4/1/2025-4/l/2026 OHC of Nebraska—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-375; Effective:4/l/2025-4/l/2026 OHC of New Jersey—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-265; Effective:4/l/2025-4/l/2026 OHC of North Carolina—Liberty Insurance Corp. -Policy#WC7-631-510199-345; Effective:4/l/2025-4/1/2026 OHC of Southwest(KS)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-425; Effective:4/l/2025-4/l/2026 Therapy Centers of Southwest I, PA(OR)-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-395; Effective:4/112025-4/1/2026 Therapy Centers of South Carolina, PA-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-305; Effective:4/l/2025-4/l/2026 OHC of Minnesota-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-455; Effective:4/l/2025-4/l/2026 OHC of Alaska-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-445; Effective:4/l/2025-4/l/2026 CYBER LIABILITY- Arch Specialty Insurance Company-Policy#NPL2001106-00; Effective: 11/25/2024-11/25/2025-Limit:$10,000,000 EXCESS CYBER LIABILITY-Homeland Insurance Company of New York-Policy#720002431-0000; Effective: 11/25/2024-11/25/2025- 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 UNDER#RQ8637 TO PROVIDE DOT MEDICAL EXAMS TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF FORT COLLINS IS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY,AUTOMOBILE LIABILITY AND EXCESS LIABILITY COVERAGES 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 10794: 3 ' of 3