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HARMONY AMBULATORY SURGERY CENTER - INSURANCE CERTIFICATE
Client#: 12582 PVHEA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D 04/02/09DIYYYY) 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 INSURER A: Copic Companies Harmony Ambulatory Surgery Center, LLC Harmony ASC Convalescent Care Center 2127 E Harmony Road Fort Collins, CO 80528 INSURER B: Safety National Casualty Company INSURER c: Federal Insurance Company 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 DATEMMIDDIYV POLICY EXPIRATION DATE MMIDD LIMITS A GENERAL LIABILITY HCC0008522 04/01/09 04/01/10 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $5O0OOO X CLAIMS MADE FX_1 OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 000 000 X Malpractice Liability Included GENERAL AGGREGATE s3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1 000 000 POLICY 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 $ F I ANY AUTO $ AUTO ONLY: AGG A EXCESS/UMBRELLA LIABILITY UCC0009293 04/01/09 04/01/10 EACH OCCURRENCE $1 O 00O 000 X OCCUR Fix] CLAIMS MADE AGGREGATE $1 O 00O 000 $ DEDUCTIBLE $ X RETENTION $ 1 O 000 B WORKERS COMPENSATION AND SP2YO7CO 04/01/09 04/01/10 X CR STATU- OTH- EfL EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1 000,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below - E.L. DISEASE - POLICY LIMIT $1 000,000 C OTHER Directors & 68006562 04/01/09_ 04/01/10 $11,000,000 Limit Officers Liab $150,000 Retention DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / 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 L:EK I IFIL:A I E HULUEK CANGELLATIUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Fort Collins DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3Q_ DAYS WRITTEN 256 W Mountain Ave NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL PO Box 580 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Ft Collins , CO 80522 1 REPRESENTATIVES. REPRESENTATIVE ACORD 25 (2001/08) 1 of 2 #M440479 NIK © 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 25S (2001/08) 2 of 2 #M440479