HomeMy WebLinkAbout461367 WORKWELL OCCUPATIONAL MEDICINE - INSURANCE CERTIFICATE (3)ACORD,. CERTIFICATE OF LIABILITY INSURANCE
OATS/O)
09/0S/2014014
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 endorsement(s).
PRODUCER
Ewing -Leavitt Insurance Agency
4025 St. Cloud Dr.
Suite ZOO
Loveland, CO 80538
CONTACT
NAME: Renee McReynolds
Pu"c°NN EM 970.679.7344 A/c,Nd:866.425.6180
ADDRess: renee-mcreynolds@leavitt.com
INSURER(S) AFFORDING COVERAGE
NAIC I{
INSURER A: Plnnacol Assurance
41190
INSURED Workwell Occupational Medicine
205 S. Main St. Ste C
Longmont, CO 80SQ1
INSURER B:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 14-15 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
MM/DO
MMIDD/YYYY
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE
$
PREMISES Eaoccueence
$
MED EXP (Anyone person)
$
PERSONAL 8 ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT OC
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY ( Per accident)
$
Per accident
$
UMBRELLA UAB
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED I I RETENTIONS
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY OFFICEWMEIM ER EXCLUDED? ECUTIVFj—
(Mandatory In NH) u
If yes descnee under
DESCRIPTION OF OPERATIONS ceIow
N /A
400660
10/01/2014
10/01/2015
X H
TORY LIMITS ER
E.L. EACH ACCIDENT
$ SQQ, QQQ
E.L. DISEASE -EA EMPLOYE
$ 500,00
E.L. DISEASE -POLICY LIMIT
$ 500,00
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD let, Additional Remarks Schedule, If more space is rm ulred)
SHOULD ANY OF THE ABOVE DESCRIBED POUCHES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins
Attn: Jim O'Neill
P 0 Box 580
Forst Collins, CO 80522
All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD