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Home My WebLink About102641 POUDRE VALLEY HEALTHCARE INC - INSURANCE CERTIFICATEAC� ® DA=2712019 YYYY) �� CERTIFICATE OF LIABILITY INSURANCE F 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). NT PRODUCER Beecher Carlson Insurance Services, LLC NAMEACT 321 North Clark Street, 5th Floor ac"N a No: Chicago, IL 60654 E-MAIL - INSURED Poudre Valley Healthcare, Inc. d/b/a Poudre Valley Hospital Inc. d/b/a Poudre Health Care Inc. 1024 S. Lemay Avenue Fort Collins CO 80524 INSURER B: Travelers INSURER C : Travelers F: Co of Amer rnVFRAAFR rFRTIFIrATF NIIMRFR• noR'I'ein RFVISION Nl1MRFR- 25674 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. POLICY EFF POLICY EXP INSR TYPE OF INSURANCE INSO SUER POLICY NUMBER MM`DD/YYYY MM LTR / D/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY Self Insured Retention 7/1/2019 7/1/2020 EACH OCCURRENCE $1000000 CLAIMS -MADE OCCUR AMAGE To R N PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY E PRO- JECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: B AUTOMOBILE LIABILITY TC2J-CAP-9F337354-18 10/1/2018 10/1/2019 COMBINED BINEDtSINGLELIMIT $2000000 BODILY INJURY (Per person) $ B or ANY AUTO TJ-BAP-9F337366-18 (APD) 10/1/2018 10/1/2019 BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DIED I I RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUC � N/A UB-9K398980-18-51-D $500K Deductible 10/1/2018 10/1/2019 �/ STATUTE ERH E.L. EACH ACCIDENT $ 1 000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ 1 000 000 If yes, describe under DESCRIPTION OF OPERATIONS below A Professional Liability Self Insured Retention 7/1/2019 7/1/2020 $1,000,000 Per Medical Incident $3,000,000 Per Annual Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I 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. f'=DTICI(`ATC LAni 111=17 rANrFI I ATIr1N City of Fort Collins Risk Management Y 9 Occupational Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 215 N. Mason Fort Collins CO 80524 AUTHORIZED REPRESENTATIVE Vim. �, G'r t,G L-t-I14C Catherine A. Levy V 1988-2015 ACUKU GUKPUKA I IUN. All rights reserveO. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 49612410 1 19-20 GL MP AU WC UMB (Poudre) I Denise Simmons 1 6/27/2019 10:36:35 AM (EDT) I Page 1 of 1