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HomeMy WebLinkAbout446619 NORTH RANGE BEHAVIORAL HEALTH - INSURANCE CERTIFICATE (6)AC" CERTIFICATE OF LIABILITY INSURANCE 6' DATE (MM/DD/YYYY) 7/3/2019 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 Professional Risk LLC 821.3 W.20th St Greeley CO 80634 CONTACT NAME: Jennifer Hunter FAX A/CONNo Ext: (970)356-8030 A/C, No: (970)356-e037 E-MAIL jennifer.hunter@proriskllc.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Philadelphia Insurance Cc 18058 INSURED North Range Behavioral Health 1300 N 17th Avenue Greeley CO 80631 INSURER B : Pinnacol Assurance 41190 INSURERC:Lloyds_of London INSURERD: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:19-20 Excess 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 W POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE OCCUR PREMISE�Ea oc urrence $ 1,000,000 X MED EXP (Any one person) $ 20,000 Professional Liability X PHPK2003795 7/1/2019 7/1/2020 PERSONAL & ADV INJURY $ 1,000,000 GENT. AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 3,000,000 POLICY a PRO- X LOC JECT PRODUCTS - COMP/OPAGG $ 3,000,000 Employee Benefits $ 1,000,000 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidentL_ $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X PHPK2003'195 7/1/2019 7/1/2020 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident) $ NON -OWNED HIRED AUTOSAUIOg S X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 X AGGREGATE S 2,000,000 A EXCESS LAB CLAIMS -MADE DED X RETENTION $ 10,000 $ PHlIB683128 7/1/2019 7/1/2020 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N X PER OTH- STATUTE. ER _I ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N /A 4044331 7/1/2019 7/1/2020 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes. describe under DESCRIPTION OF OPERATIONS below --- E.L. DISEASE - POLICY LIMIT -- $ 1, 000 - 000 C Privacy ESI031174750 7/1/2019 7/1./2020 Aggregate $ 3,000,000 A HIPAA Violation PHSD1459980 7/1/2019 7/1/2020 Limit $ 50,000 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 additional insured as pertains to the General and Auto Liability policies, per written contract. CERTIFICATE HOLDER CANCELLATION City of Fort Collins -Financial Services Purchasing Division PO Box 580 Fort Collins, CO 80522 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 Dionne Perez/DP�+r��y__.rRG'�� © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401)