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HomeMy WebLinkAboutMCR SURGERY CENTER LLC - INSURANCE CERTIFICATEACORD,., CERTIFICATE OF LIABILITY INSURANCE 0DATE 5/04/090nvvv 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 MCR Surgery Center, LLC Poudre Valley Health System 2500 Rocky Mountain Ave Loveland, CO 80538 INSURER A: Copic Companies INSURER B: Safety National Casualty Company 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 POLICY EXPIRATION DATE(MI LIMITS A GENERAL LIABILITY HCC0008522 04/01/09 04/01/10 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGETORENT.EOnan $500000 X I CLAIMS MADE FXI OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1000000 X Malpractice Liab GENERAL AGGREGATE s3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $1 000000 POLICY JECPRD T 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 AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AEG A EXCESS/UMBRELLA LIABILITY UCC0009293 04/01/09 04/01/10 EACH OCCURRENCE $1 Q 000 000 X OCCUR Fx-] CLAIMS MADE AGGREGATE $1 O 000 000 $ $ DEDUCTIBLE $ X RETENTION $ 10 000 B WORKERS COMPENSATION AND SP2YO7CO 04/01/09 04/01/10 X WCSTATu OTH EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1 OOO OOO E.L. DISEASE- EA EMPLOYEE $1,000,000 OFFICER/MEMBER EXCLUDED? Excess Coverage It yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $1 00O 000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ 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 REPRESENTATIVE ACORD 25 (2001/08) 1 Of 2 #M442936 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. AGOHO 25-5 (2001/00) 2 of 2 #M442936