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Home My WebLink About102641 POUDRE VALLEY HEALTHCARE INC - INSURANCE CERTIFICATE (2)® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 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 Shelby Douglass 321 North Clark Street, 5th Floor PHONE FAX Chicago, IL 60654 E-MAIL Ext: AIC No: INSURED INSURER B Poudre Valley Healthcare, Inc. d/b/a Poudre Valley Hospital Inc. d/b/a Poudre Health Care Inc. INSURERC: 1024 S. Lemay Avenue INSURER0: Fort Collins CO 80524 CnVFRAGFS CFRTIFICATF NIIMRFR• A01AA1an RFVICIr)N MIIMRFR- 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 OF INSURANCE AIDDLSUBRTYPE INSD WVD POLICY NUMBER MM / D/YYYY MM DDIYYYY LIMITS A �/ COMMERCIAL GENERAL LIABILITY Self Insured Retention 7/1/2019 7/1/2020 EACH OCCURRENCE $1000000 CLAIMS -MADE 171 OCCUR A A E ENTED PREMISES Ea occurrence _ $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JET LOC PRODUCTS-COMPlOP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB I CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER E.L. EACH ACCIDENT $ ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) NIA ---- -- $ E.L. DISEASE - EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below - - $ E.L. DISEASE - POLICY LIMIT A Professional Liability Self Insured Retention 7/1/2019 7/1/2020 $1,000,000 Per Medical Incident DESCRIPTION OF OPERATIONS / LOCATIONS / 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. Cityy of Fort Collins ATTN: Purchasing Department PO Box 580 Fort Collins CO 80522 N 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 Catherine A. Levy ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 49568160 1 19-20 GL MP AU WC UMB (Poudre) I Shelby Douglass 1 6/26/2019 1:35:18 PM (EDT) I Page 1 of 1