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HomeMy WebLinkAbout482592 POUDRE VALLEY HEALTH SYSTEM - INSURANCE CERTIFICATE,aco CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 have ADDITIONAL INSURED provisions or 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 Beecher Carlson Insurance Services, LLC NAME: CONTACT 321 North Clark Street, 5th Floor PHONE FAX Chicago, IL 60654 E-MAIL - [A/C. No): INSURER A: Steadfast Insurance Company INSURED INSURER B Poudre Valley Health Care, Inc. d/b/a Poudre Valley Health System and Poudre Valley Hospital INSURER C: 2315 E. Harmony Rd., Suite 200 INSURERD: Fort Collins CO 80528 INSURER E: rr1VFRAr:9S. rFRTIFIrATF NIIMRFR• nn1')01an RFVIRION NIIMRFR- 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. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ HPC 9327153-05 10/1/2018 10/1/2019 EACH OCCURRENCE $1 000 000 CLAIMS -MADE ,/ OCCUR DAMA RENTED PREMISES Ea occurrence $ 5O 000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 ✓ POLICY JE� LOC PRODUCTS -COMP/OPAGG $1,000000 $ OTHER: AUTOMOBILE LIABILITY MBINED SINGLE LIMIT (CEO, accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DIED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYP RDPRI ETD R/PARTN ER/EX EC UT I VE STATUTE ER E.L. EACH ACCIDENT $ OFFIC ERiM EMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ A Professional Liability HPC 9327153-05 10/1/2018 10/1/2019 ea occ: $1,000,000/ agg: $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Services provided to the Occupational Health Clinic, 256 W. Mountain AVE, Fort Collins, CO 80521, the City of Fort Collins is listed as additional insured to General Liability. UhK I IhIL;A I t NULUtK City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: Purchasing Department ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 580 Fort Collins CO 80522 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 44329180 1 18-19 GL MP AU UMB WC (POUDRE) I (PROV) Denise Simmons 1 9/20/2018 2:07:56 PM (EDT) I Page 1 of 1