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Home My WebLink AboutHARMONY IMAGING CENTER POUDRE VALLEY HEALTH SYSTEM - INSURANCE CERTIFICATEPVHEA Client#: 12582 ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE 04/02/09D ) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Flood 8r 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 INSURER A: Copic Companies Harmony Imaging Center, LLC dba Poudre Valley Health System 2315 E Harmony Road, Suite 200 j Fort Collins, CO 80528-8620 INSURER B: Pinnacol Assurance INSURER C: INSURER D: 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 Y POLICY EXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY HCC0008522 04/01/09 04/01/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED nce $500OOO X CLAIMS MADE N OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 00O 000 X Malpractice Liability Included GENERAL AGGREGATE s3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1 000 000 POLICY F PRO LOC JECT 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 AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESS/UMBRELLA LIABILITY UCC0009293 04/01/09 04/01/10 EACH OCCURRENCE $10 000 000 X OCCUR a CLAIMS MADE AGGREGATE $10000 000 $ $ DEDUCTIBLE FX]RETENTION $ $ 10000 1 B _WORKERS COMPENSATION AND 4054594 04/01 /09 04/01/10 _ X WC STATU- OTH- RY EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $100000 E.L. DISEASE - EA EMPLOYEE $100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3n DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) 1 of 2 #M440474 NIK O ACORD CORPORATION 1988 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. ACORD 25-S (2001/08) 2 of 2 #M440474