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HomeMy WebLinkAboutCORRESPONDENCE - FAX QUOTE - 8637 DOT MEDICAL EXAMSThe ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS PER STATUTE OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: CONCGRO-01 1 1 The Graham Company Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 25 CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-3; Effective 6/1/2018-2019 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-3; Effective 6/1/2018-2019 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-3; Effective 6/1/2018-2019 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-3; 6/1/2018-2019 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-3; 6/1/2018-2019 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Policy #WA7-63D-510199-048; Effective: 6/1/2018-2019 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Policy #WA7-63D-510199-058 and WC7-631-510199-068; Effective: 6/1/2018-2019 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas – Policy #WC7-631-510199-078; Effective: 6/1/2018-2019 OHC of Southwest (AZ/UT) – Policy #WC2-631-510199-118; Effective: 6/1/2018-2019 OHC of Delaware – Policy #WC2-631-510199-108; Effective: 6/1/2018-2019 OHC of Georgia/Hawaii – Policy #WC2-631-510199-178; Effective: 6/1/2018-2019 OHC of Illinois – Policy #WC2-631-510199-198; Effective: 6/1/2018-2019 OHC of Louisiana – Policy #WC2-631-510199-098; Effective: 6/1/2018-2019 OHC of Michigan – Policy #WC2-631-510199-188; Effective: 6/1/2018-2019 OHC of Nebraska – Policy #WC2-631-510199-148; Effective: 6/1/2018-2019 OHC of New Jersey – Policy #WC2-631-510199-138; Effective: 6/1/2018-2019 OHC of North Carolina – Policy #WC7-631-510199-088; Effective: 6/1/2018-2019 OHC of Southwest (KS) – Policy #WC2-631-510199-128; Effective: 6/1/2018-2019 Therapy Centers of Southwest I, PA (OR) - Policy #WC2-631-510199-168; Effective: 6/1/2018-2019 Therapy Centers of South Carolina, PA - Policy #WC2-631-510199-158; Effective: 6/1/2018-2019 CYBER LIABILITY - National Union Fire Insurance Company of Pittsburgh, PA - Policy #01-950-31-88; Effective 9/25/2018-2019 - Limit: $10,000,000 Security and Privacy EXCESS CYBER LIABILITY - Endurance American Insurance Company - Policy #PRX10009889402; Effective: 9/25/2018-2019 - Limit: $10,000,000 Each Occurrence/Aggregate Coverage is provided for all medical professionals employed or contracted by the above Named Insured, only while working for or on behalf of the above Named Insured. RE: OHC-SWPA/CMC HAS AN AGREEMENT UNDER # RQ8637 TO PROVIDE DOT MEDICAL EXAMS TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF FORT COLLINS IS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY, AUTOMOBILE LIABILITY AND EXCESS LIABILITY COVERAGES IF REQUIRED BY WRITTEN CONTRACT. PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10/19/2018 The Graham Company The Graham Building 1 Penn Square West Philadelphia PA 19102- SelectMed Unit 215-567-6300 215-525-0243 SELECTMED_UNIT@grahamco.com Columbia Casualty Company 31127 CONCGRO-01 American Guarantee & Liability 26247 Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 Liberty Mutual Fire Ins. Co. 23035 Allied World Assurance Company, Ltd. (DOMICILED Liberty Insurance Corporation 42404 Liberty Mutual Insurance Group 23043 1281722352 A X 1,000,000 X 500,000 X Professional Lia 10,000 X $1M Claim/$3M Ag 1,000,000 3,000,000 X Y HAZ 4032244581-3 6/1/2018 6/1/2019 3,000,000 C 2,000,000 X Y AS2-631-510199-038 6/1/2018 6/1/2019 A X X 10,000,000 2,000,000 Y HMC 4032235752-3 X 10,000,000 6/1/2018 6/1/2019 E F N WA7-63D-510199-018 WC7-631-510199-028 6/1/2018 6/1/2018 6/1/2019 6/1/2019 X 1,000,000 1,000,000 1,000,000 B D Property Excess Liability ZMD0119116-03 C023701-004 6/1/2018 6/1/2018 6/1/2019 6/1/2019 SEE BELOW $10M Each Occurrence $10M Aggregate UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $2,000,000 Self-Insured Retention each Occurrence/Claim subject to a $10,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-3; Effective 6/1/2018-2019 - $400,000 Each Medical Incident/$1,200,000 Aggregate Per Insured or Surgeon See Attached... CITY OF FORT COLLINS PO BOX 580 ATTN: PURCHASING DIRECTOR FORT COLLINS CO 80522 THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE