HomeMy WebLinkAboutCOLUMBINE HEALTH SYSTEMS - INSURANCE CERTIFICATE (6)A1 ®
� o CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYYI
6/30/2020
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 andorsement(s).
PRODUCER
Professional Risk LLC
CONTACT
NAME: Dionne Perez _ -
PHONE P�I. (970)356-8030 aC No), (970)336-e032
ADDRIESS:dionne.perez@proriskllc.com
8213 w.20th St
INSURERS AFFORDING COVERAGE
NAIC.O-
IN$ RERA:HEALTH CARE INDUSTRY LIABILITY RECIPROC
11832
Greeley CO 80634
INSURED
INSURER B:
INSURERC:
Columbine Management Services, DBA: Columbine
INSURERD:
Health Systems - -
INSURERE:
802 W Drake Rd Ste 101
INSURER F:
Fort Collins CO 80526 _
rnvooencc r r-RTIFICATF Nt1MRFR'20-21 Management kEVI51VN numorK:
THIS IS TO CERTIFY THAT THE POLICIES-OF..INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD -
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE .MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJECT TOALLTHE TERMS,
EXCLUSIONS' AND, CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: "
INSR
LTR
TYPE OF INSURANCE
.._ n
B
POUCYNUMBER_ _
"
MMOIUDDYNYYY
POLICY EXP
MWDD
X
COMMERCIAL GENERAL LIABIUTY
.. ..
...
EACH OCCURRENCE -
$ 1,000,000
A
CLAIMS MADE a OCCUR.
DAMAGE TO RENTED
PREMISE Ea occurrence
_ __ _ .
$ 100, 000
X
.MED.EXP(Any -one person)
$ 5,600
PROFESSIONAL LIABILITY
X
HRGCO010001OC17
7/1/2020
7/1/2D21
-
PERSONAL B ADV.INJURY
$ 1,660,000
..
GEN'L AGGREGATE LIMIT APPLIES PER:
- _
..GENERAL AGGREGATE_. __..
$ 3,000, 000
- . AGG
. 3,000,000
PRO.
POLICY JECT LOC
_Eploee Benefits
$ 1,000,000
OTHER:
,
AUTOMOBILE LIABILITY
COMBINED
Eaa acd rd) ELM
S
BODILY _INJURY (Per person)
S'
ANY AUTO
BODILY INJURY (Per awdent)'
$
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUT( AUTOS
'PROPERTY DAMAGE
Per atoideM ..
S
-
'
UMSRELLA.LIAB
OCCUR
.EACH OCCURRENCE___...
$ -
AGGREGATE.. _
EXCESS UAB
CLAIMS -MADE
DED_ ...RETENTION:$
-
WORKERS COMPENSATION - .
AND EMPLOYERS' LIABILITY IN
ANY- PROPRIETOR/PARTNERIEXECUTIVE Y❑
-
-
PERH-
T
R
- - - - - -
E.L.EACH ACCIDENT
$
-
E L DISEASE - EA EMPLOYEE
- - -'
$
-
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) - _
NIA
E.L. DISEASE -POLICY. LIMIT
S____.
If yes, tlescdDe under
DESCRIPTION OF OPERATIONS below..
DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Addhlonal Remarks Schedule, may be attached If men space Is nqulmd)
Re: License Cl-B. City of Fort Collins is listed as additional insured as pertains to the General
Liability policy, per written contract.
rcoTtctr A7•c 1Jnl noD CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Fort Collins
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCEWITH THE POLICY PROVISIONS.
PO Box 580
Fort Collins, CO 80522
AUTHORIZED REPRESENTATIVE
Dionne Perez/DP��
W l`JOD-Luis AI,VRV VVRI'VRi11Vly. All IIa11W ICJ61vOY..
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)