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Home My WebLink AboutHARMONY AMBULATORY SURGERY CENTER LLC - INSURANCE CERTIFICATEACORD,M CERTIFICATE OF LIABILITY INSURANCE 03ATE /26/08D1 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Flood & Peterson Insurance Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4821 Wheaton Drive HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW P O Box 270370 Fort Collins CO 80527 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA Copic Companies Harmony Ambulatory Surgery Center LLC INSURER B Safety National Casualty Company Harmony ASC Convalescent Care Center INSURER c Federal Insurance Company 2127 E Harmony Rd Fort Collins CO 80528 INSURER 0 INSURER E COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DDM' LIMITS A GENERAL LIABILITY HCC0008522 04/01/08 04/01/09 EACH OCCURRENCE $1 00Q 000 X COMMERCIAL GENERAL LIABILITY X I CLAIMS MADE Fx1 OCCUR DAMAGE TO RENTEDPREMISES Ea,ccccrence) $5OO 00Q MED EXP (Any one person) $5 000 PERSONAL BADVINJURY $1000000 X Malpractice Liability Included GENERAL AGGREGATE s3,000,000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $1 00O 000 POLICY 7 PECOT LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTOONLY EAACCIDENT $ OTHERTHAN EA ACC $ ANY AUTO $ AUTO ONLY AGG A EXCESS/UMBRELLA LIABILITY X OCCUR 7CLAIMS MADE UC00009293 04/01/08 04/01/09 EACH OCCURRENCE $10000000 AGGREGATE $1000000-0 $ DEDUCTIBLE $ X RETENTION $ 1O 000 B WORKERS COMPENSATION AND SPIN19CO 04/01/08 04/01/09 X I TWC STATU OTH IE EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E L EACH ACCIDENT $1 000 000 E L DISEASE EA EMPLOYEE $1 OOO 000 OFFICER/MEMBER EXCLUDED? If yes describe under SPECIAL PROVISIONS below Excess Coverage E L DISEASE POLICY LIMIT $1 Q00 000 C OTHER Directors & 68006562 04/01/08 04/01/09 $11 000 000 Limit Officers Liab DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Health Professional Liability Persons Included (if applicable) Professional employees of the named insured other than physicians Professional students of the named insured other than residents Volunteers of the named insured other than physicians and residents City of Fort Collins 256 W Mountain Ave PO Box 580 Ft Collins CO 80522 I ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION IEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO 50 SHALL NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR ACORD 25 (2001/08) 1 of 2 1IM409947 nvQ (a ACORn CrTRprTRATInN 1ORA IMPORTANT If the certificate holder is an ADDITIONAL INSURED the policy(ies) must be endorsed A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) 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) DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s) authorized representative or producer and the certificate holder nor does it affirmatively or negatively amend extend or alter the coverage afforded by the policies listed thereon Awwu zos (zuuvua) 2 of 2 #M409947