HomeMy WebLinkAbout446619 NORTH RANGE BEHAVIORAL HEALTH - INSURANCE CERTIFICATE (3)NORTH12 OP ID: DP
A�oRo. CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DDYYYY)
0612812013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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 endorsements .
PRODUCER :... '+ - - - - Phone: 970-356-8030
Rich & Cahniili Ins of CO Fax: 970-356-8032
of Colorado LLC
8213 W. 20th Street
Greeley, CO 80634
Michael J Schmitt CIC 1 11I �1
CONTACT
NAME: !-
PHONE - A/D No): _
_(NC No Eat:
ADDRESS: - -
Insure
NAICk
cCOVERAGE
delphia
INsuRERA:Philadel hie Insurance Co
23850
INSURED North Range Behavioral Health
INSURERB:Pinnacol Assurance
INSURER C:
1300 N 17th Avenue
Greeley, CO 80631
INSURER 0:
INSURER E :
INSURER F:
rn.Icoan_oc CERTIFIr ATF WI MRFR- REVISION NUMBER:
V THIS, IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAf6ED 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN
LTR
TYPE OF INSURANCE
ADDL
UB
POLICY NUMBER
POLICY EFF
MMIDO/ YYY
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,00
A
X COMMERCIAL GENERAL LIABILITY
X
PHPK1043975
07/01/2013
07/01/2014
PREMISES(Ed occurrence
$ 1,000,00
MED EXP (Any one person)
$ 20,00
CLAIMSWADE a OCCUR
PERSONAL B ADV INJURY
$ 1,000,00
X HIPAA Included
GENERAL AGGREGATE
S 3,000,00
-
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO
S 3,000,00
Emp Ben. _
$ 1,000,00
POLICY _ 'PRO-. JECTLOG
-
'
AUTOMOBILE LIABILITY-
'
_
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,00
BODILY INJURY (Per person)
$
A -
X ANY AUTO-
.PHPK1043975
07/01/2013
07/01/2014
BODILY INJURY (Per accltlent)
$
ALL OWNED . SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
Per acdtlenl
$
X
UMBRELLA LIAR
X
OCCUR
EACH OCCURRENCE
$ 2,000,0013
1-1
AGGREGATE
S 2,000,00
A
EXCESS LIAR
CLAIMS -MADE
PHUB427339
07/01/2013
07/01/2014
DED I X I RETENTION$ 10,000
$
WORKERS COMPENSATION
X VJC STATU- 2
B
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNEP/EXECUTIVE Y/N
OFFICERIMEMBER EXCLUDED?
(M andatory in NH)
NIA
4044331
07/01/2013
07/01/2014
E.L. EACH ACCIDENT
$ 100,00
E.L. DISEASE -EA EMPLOYEE
$ 100,00
E.L. DISEASE -POLICY LIMIT
'$ 'SGO,00
If yes, describe Oder
DESCRIPTION OF OPERATIONS be.
A
Crime
PHSD757635
07/01/2013
07/01/2014
Crime 60,00
A
Professional Liab
PHPK1043975
07/01/2013
07/01/2014
Prof Liab 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace Is required)
City of Fort Collins, Colorado, a Municipal Corporation, is listed as
additional insured as their interest may appear.
CITFOR
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins, Colorado ACCORDANCE WITH THE POLICY PROVISIONS.
A Municipal Corporation
300 LaPorte Ave AUTHORIZED REPRESENTATIVE
PO Box 580 Michael J Schmitt CIC
Fort Collins, CO 80522
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