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HomeMy WebLinkAbout482592 POUDRE VALLEY HEALTH SYSTEM - INSURANCE CERTIFICATE (2),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). CONTACT PRODUCER Beecher Carlson Insurance Services, LLC NAME: 321 North Clark Street, 5th Floor PHONE FAx Chicago, IL 60654 E-MAIL _Ext): (A/C. No): INSURED INSURER B Poudre Valley Health Care, Inc. d/b/a Poudre Valley Health System and Poudre Valley Hospital INSURERC: 2315 E. Harmony Rd., Suite 200 INSURER D: Travelers Fort Collins CO 80528 INSURER E: Travelers Co of Amer COVERAGES CERTIFICATE NUMBER 1&19Q1R1 REVISION NUMBFR- 25658 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 TYPE OF INSURANCE ADDL SUER POLICPOLICY NUMBER MMJ DY/YYYY MM/DDNYYY LIMITS LTR A �/ COMMERCIAL GENERAL LIABILITY HPC 9327153-05 10/1/2018 10/1/2019 EACH OCCURRENCE $1 000 000 CLAIMS -MADE OCCUR E. DAMAGE TRENTED PREMISES Ea occurrence $ 50 OOO 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-COMPJOP AGG $ 1 000 000 $ OTHER: D D AUTOMOBILE LIABILITY ANY AUTO TC2J-CAP-9F337354-18(AL) TJ-BAP-9F337366-18(APD) 10/1/2018 10/1/2018 10/1/2019 10/1/2019 OMBI EDtSINGLELIMIT $2000000 BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTYDAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY AL deductible $ $25 000 UMBRELLA LIAB _ OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERiEXECUTIVE Y❑ OFFICER/MEMBER EXCLUDED? N N/A UB-9K398980-18-51-K $500K deductible 10/1/2018 10/1/2019 // I STATUTE I ERH E.L. EACH ACCIDENT _ $ 1 OOO OOO E.L. DISEASE - EA EMPLOYEE $ 1 0D (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 00O 000 A Professional Liability HPC 9327153-05 10/1/2618 10/1/2019 ea occ: $1,000,000/ agg: $3,000,000 retro date: 5/1/1994 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Fort Collins is listed as an additional insured with respect to General Liability only. Professional liability limits include errors and omissions coverage. CERTIFICATE HOLDER CANCELLATION City of Fort Collins Risk Management Occuppational Health 215 N. Mason Fort Collins CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 44329181 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