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HomeMy WebLinkAboutCIGNA CORPORATION - INSURANCE CERTIFICATE (3)CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YIYY) 06/24/2015 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 AOn Risk Services Central, Inc. Philadelphia PA Office CONTACT NAME: (AIC.NNo. Ext): (666) 283-7122 FAX Nc is (800) 363-0105 E-MAIL ADDRESS: One Liberty Place 1650 Market Street Suite 1000 Philadelphia PA 19103 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: ACE American Insurance Company 22667 Ci Qna Corporation Et Al INSURER B: ACE Fire Underwriters Insurance Co. 20702 900 Cottage Grove Road Bloomfield CT 06002 USA INSURER C: Indemnity Insurance Co of North America 43575 INSURER D: Agri General Insurance Company 42757 INSURERS: American Guarantee & Liability Ins Co 26247 INSURER F: COVERAGES CERTIFICATE NUMBER: 570058220391 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 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. Limits shown are as requested ILTR TYPE OF INSURANCE NSD WVD POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG 1 1 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X❑ OCCUR DAMAGE T D $1,000,000 PREMISES Ea occurrence MED EXP (Any one person) $ 5 , 000 PERSONAL & Al INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3 , 000 , 000 X POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $1,000,000 OTHER. A AUTOMOBILE LIABILITY ISA H08856710 07/01/2015 07/01/2016 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE HIREDAUTOS NON -OWNED Per accident AUTOS Medical Payments Lia $ 5 , 000 E X UMBRELLA LAB X OCCUR AuC967096607 07/01/2015 07/01/2016 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $25,000,000 DED I RETENTION C WORKERS COMPENSATION AND WLRC48149339 07/01/2015 07/01/2016 X I PER STATUTE EORH EMPLOYERS' LIABILITY YIN (AOS) E.L. EACH ACCIDENT $1,000,000 A ANY PROPRIETOR / PARTNER / EXECUTIVE NIA WLRC48149327 07/01/2015 07/01/2016 OFFICERIMEMBEREXCLUDE., (Mandatory in NH) (CA , MA) E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 A Excess WC WCUC48149352 07/01/2015 07/01/2016 EL Each Accident $1,000'000 (OH) EL Disease - Policy $1, 000,000 SIR applies per policy terms & conditions EL Disease - Ea El $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Named Insured includes: Cigna Health and Life Insurance Company, 900 Cottage Grove Road, Bloomfield, CT 06002. RE: Proof of insurance for REP No. 7649. City of Fort Collins, its officers, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Fort Collins AUTHORIZED REPRESENTATIVE 215 N. Mason Street, 2nd Floor Fort Collins CO 80522 USA JV. A�„ `m ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10042023 LOC #: `4C ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk Services Central, Inc. NAMED INSURED Cigna Corporation Et Al POLICY NUMBER See Certificate Number: 570058220391 CARRIER See Certificate Number: 570058220391 NAIC CODE EFFECTIVE DATE. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liabilitv Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL INSD St WVD POLICY NC�IBER POLICY EFFECTIVE DATE (MM/DDNYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) LIMITS WORKERS COMPENSATION B N/A SCFC48149340 (WI) 07/01/2015 07/01/2016 A N/A wLRC48150652 Workers Comp (MI) 07/01/2015 07/01/2016 A N/A WLR c48150664 workers Comp (NY) 07/01/2015 07/01/2016 A N/A wLR C48150640 workers Comp (KS) 07/01/2015 07/01/2016 D N/A wLRc48149364 workers Comp (TN) 07/01/2015 07/01/2016 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD