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ORDTM CERTIFICATE OF LIABILITY INSURANZE -- 12/09/2010YYY,
PRODUCER
THIS CERTIFICATE IS ISSUE-) AS A MATTER OF INFORMATION
New York - Executive Risk
I'99 Park Ave„Suite 1.91U
ONLY AND CONFERS NO R; ?:HTS-UPON 'THE CERTIFICATE
HOLDER. THIS'CERTIFICATi DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE 'AF•i;ORDED BY -THE POLICIES BELOW.
New'York,.'NY 10016
--
INSURERS AFFORUING COVL`'.AGE
NAIC #
INSURED
Alliant Holdings I, Inc.
1301 Dove Street, Suite 200
Newport Beach, CA 92660
INSURERA: Darwin Select Ins.`irance COm pany
—"
24319
_
—'--"—"
INSURER B:
INSURER C:
_
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE !NSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E:CLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
N R
LTR
DO
NSR
TYPE OF INSURANCE
POLICY NUMBER
_
POLICY EFFECTIVE
DATE MMIDDNY
POLICY EXPIRATION' LIM.!TS
DATE MM/DDIYY) _
I -
-
GENERAL LIABILITY
.-r•n��np c'Pr.;rL GENErL�L LIABI!.!TY
CLAIMS MADE U OCCUR
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..,:. ...
j EACH OCCURRENCE
• I DAMAGE TO. RENTED
PRFMIS°'S 'tom GC^ P
rj MED EXP (Any oneperson)
PERSONAL & ADV INJURY
.GENERAL .AGGREGATE
I_>,PRODUCTS - COMP/OP AGG
_. •=.. -
$
$
$
S
$
GEN'L. AGGREGATE LIMIT APPLIES PER:
PRO. '-
POLICY• - JECT LOC
$
-
_
AUTOMOBILE
LIABILITYLIMIT
ANY AUTO
ALL OWNED AUTOS
+SCHEDULED AUTOS!
HIRED AUTOS --
'NOWOWNED S '" ^�
• as -,
�•
� � -
-
,..
COMBINED SINGLE L
- :;,�� (Ea accident)
'S
�S,(Perperson)BODILY INJURY.}.. �
� ,:.,
}L:, 'BODILY INJURY
'},,,(Per
C(Per accident) " •
f s
`y1PROPERTY-DAMAGE-1
(Per accident)
$ _
.$ _-; •
$ t •., •_ ,
$'-
c,
GARAGc LIABILITY q, -
ANY AUTO - • �•
EXCESSiUMBRELLA LIABILITY
- OCCUR» -"CLAIMS MADE-'
_ DEDUCTIBLE.
RETENTION $ -
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORYPARTNER/EXECUTIVE
QFF-I0.ER'MEVI]ER EXCL DED'
If yes, describe under - -
SPECIAL PROVISIONS below
I
.AUTO ONLY - EA ACCIDENT.
I - I OTHER THAN EA ACC
"AUT0ONLY: AGG
I EACH OCCURRENCE
AGGREGATE
ri
I
. WG STATU;' OTH-
FIR
i E.L. EACH ACCIDENT
j E.L. DISEASE -PA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
.$ _
$
$
$ '
$
$
$
-
$
A
OTHER -Professional
Liability
03042663
12/15/10
12/15/11,$,15,000,00 .O,Each Claim
:$15,000,000 Aggregate
i $1,000,060 Retention
DESCRIPTION OF OPERATIONS / LOCATIONS % VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL. PROVISIONS
This is a Claims Made Policy.
See Attached Narried lrisured List:-: '
(See Attached; Descri tions) .p
M.'City,bf Fort'C'ollins, CO
'215'-N6`rtn'Mason St., 2nd FL
Fort Collins,, CO 80524
SHOULD ANY OF THE ABOVE OESCRI •,`.OPOLICIES BE CANCELLED:BEFORE-THE EXPIRATION.
DATE THEREOF, THE ISSUING INSURE';:IV!LL ENDEAVOR TO MAIL U DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER'lAMED;T.O THE,LEFT, BUT FAILURE.TO DO SO.SHALL .
IMPOSE NO OBLIGATION OR LIABILITY F;ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
AU
THQRIZED REPRESENTATIVE .-.
ACORO 25 (2001/08):1 of.3 7 #S13403/M12496 L!RL 0 ACORD CORPORATION 1988
IMPORTANT
If the' certificate holder is an ADDITIONAL INSURED, the policy(ies) must be Fadorsed. A statement
on .this certificate does hot confer -rights to the certificate holder in lieu of such enoorsement(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 ric,,its. to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER. _.
The Certificate of Insurance on the reverse side of this form does not constitu`.' •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.
CORD 25-5 (2001/08) 2 of 3 #S13403/M12496
'DESCRIPTIONS (C-0'0'tihileddl
THE NAMED INSURED INCLUDES
THE FOLLOWING ADDITIONAL ENTITIES:
S:
Affinity Insurance, Services, LLC
Alliant, Holdings 1, Inc.
Alli.an,t Holdings 11, Inc..
Alliant Insurance Services, Inc.
Alliant Insurance Services Houston, LLC
Alliant Reso ' Urces,Group, Inc.
Alliant Specialty Insurance Services, Inc.
Alliant Services Houston, Inc.
ARG Holdings, Inc..
Benefit Management, Inc.
Benefit Partners, LLC
Benefit Partners-Alliant, Inc.
Clarity Benefit Consult ing, LLC,
�'0riC 6arPoiC . P
Colonial Healthcare, Inc..
FHI Benefit Plans, Inc.dba: FHl Insurance Services
Franey Muha. Alliant Insurance Services, Inc.
Gaddy -Ward-& Company Insurance Brokers,
Jon Donovan Tanner Insurance Agency, Inc.,,,.
Kelter-Alliant InsuranceServicvs, Inc. dba Proquest Insurance Agency
Moore McNei! LLC
Strategic HR Services, Inc.
AMS 25.3 (2001/03) 3 of 3 #S13403/M12496