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Home My WebLink About264874 OCCUPATIONAL HEALTH SERVICES - INSURANCE CERTIFICATEClient#: 12582 PVHEA ACORD- CERTIFICATE OF LIABILITY INSURANCE ,2/21/ 09 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 - Occupational Health Services Poudre Valley Health System 4674 Snow Mesa Dr, Suite 200 Fort Collins CO 80528 INSURERB: Safety National Casualty Company INSURER 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. INSR LTR DD' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MWDD POLICY EXPIRATION DATE (MMn)Drrfl LIMITS A GENERAL LIABILITY HCC0008522 04/01/09 04/01/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ce PREMISES (Ea occurren ) $500OOO X I CLAIMS MADE 51OCCUR MED EXP (Any one person) $5, 00Q PERSONAL &ADV INJURY $1 000 000 X Malpractice Llab Included GENERAL AGGREGATE $3 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1000000 _ POLICY JEo- El LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS - (Per person) BODILY INJURY $ . HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO _ $ AUTO ONLY: AGG A EXCESSIUMBRELL.A LIABILITY UCC0009293 04/01/09 04/01/10 EACH OCCURRENCE $10 000 000 X OCCUR Fx-] CLAIMS MADE - AGGREGATE $1 O 00O 000 $ $ H- DEDUCTIBLE - $ X RETENTION $ 10 0O0 B WORKERS COMPENSATION AND SP2YO7CO 04/01/09 04/01/10 X WC STATUMIT- O R EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $1,000,000 OFFICER/MEMBER EXCLUDED? - Excess Coverage ff SPECAdescribe ROVISIONS 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 i 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 Purchasing Division PO Box 580 Ft Collins , CO 80522 I IUN LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30_ DAYS WRITTEN :E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) 1 Of 2 #S495060/M441008 NIK I 10 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. AUUKU LO-1 (LUU7/U5) 2 of 2 #S4950601M441008