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HomeMy WebLinkAbout541195 MARATHON HEALTH INC - INSURANCE CERTIFICATE-om:Amy Merritt FaxID:HBInsuranceGroup Date:2/24/2016 12:05:27 PM Page: 3 of 6 MARAHEA-01 AMERRITT '44CORL> CERTIFICATE OF LIABILITY INSURANCE `•--� FDATE(MM/DD/YYYY) 2/24/2016 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 Hickok & Boardman, Inc. 346 Sheiburne Rd Burlington, VT 05401 NAME: Amy Merritt PHONE 802 383-1657 FAX (802) 658-0541 AIC No EXc : ( ) vc No ADDRESS: amerritt@hbinsurance.com INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: Columbia Casualty Co 31127 INSURED INSURER B : Hartford Casualty Ins Co Marathon Health, Inc. INSURER C : Endurance American Specialty Ins Co 41718 INSURER D : 20 Winooski Way, Suite 400 Winooski, VT 05404 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: RFVlglntJ NIIMRFR- 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 TYPE OF INSURANCE ADDL INSD SUBRI WVD I POLICY EFF POLICY NUMBER MM/DDiYYY POUCY EXP MM1DDlYYYY LIMITS A X COMMERCIAL GENERA��L��LIABILITY EACH OCCURRENCE $ 5,000,00 CLAIMS -MADE OCCUR X HMA 1064390164-11 l 01/19/2016 01l19l2017 'REMISES Ea occurrence S 100,00 MED EXP (Any one person) $ 5,00 PERSONAL 8 ADV INJURY S 5,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,00 PO- POLICY D JECT El LOC X PRODUCTS - COMP/OP AGG S 5,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000 OO , BODILY INJURY (Per person) $ B ANY AUTO 04SBAUK8133 101/19/2015 01119/2017 ALL OWNED SCHEDULED AUTOS AUTOS j 1 BODILY INJURY (Per accident) $ X X NON -OWNED HIRED AUTOS AUTOS i j PROPERTY DAMAGE Per accident $ $ I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,00 A X EXCESS LIAB X CLAIMS -MADE X HMC 4031941072-4 ! 01/19/2016 01119/2017 AGGREGATE $ 5,000,00 DEDT I RETENTION $ $ a WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A 04WBCCN9509 01/1912016 '.. 01119/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ SOO,OO E.L. DISEASE - EA EMPLOYEE S 500,00 H yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500,00 A Professional Liab. _ HMA 1064390164-11 01119/2016 01/19/2017 Claims Made Coverage 5,000,00 C Cyber Liability X EPP02010114 01/19/2016 01/19/2017 Per Claim $ Agg 5,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Named insured includes, Marathon Health, Inc., MH 101, PC, MH Health Care Services, PC, MH Medical Services, PC, MH Nursing of Indiana, PC, Marathon Nurse Practitioner in Adult Health, PC, MH Nursing of California, PC and MH Health of Kansas, PA. Professional Liability claims retro date on professional policy: 01.19.2005 Cyber liability claims retro date: 05/29/2009 City of Fort Collins is listed as an additional insured, as required by written contract or agreement, on the general liability policy per form CG 2026 (and the SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION City of Fort Collins 300 LaPorte Ave Fort Collins, CO 80521 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 n ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD -om:Amy Merritt FaxID:HBInsuranceGroup Date:2/24/2016 12:05:27 PM Page. 4 of 6 / 1 ACORO' ilk.� AGENCY CUSTOMER ID: MARAHEA-01 LOC #: 1- ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED ickok &Boardman, Inc. Marathon Health, Inc. .............................................................................................._. . ........................ Winooski, VT 05404 POLICY NUMBER EE PAGE 1 ................... ........................................................................... _................................................. _........... ........ CARRIER NAIC CODE EE PAGE 1 ISEEP 1 EFFECTIVE DATE: SEE PAGE 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance AMERRITT Page 1 of 1 Description of Operations/Locations/Vehicles: excess policy follows form, including additional insured status.) City of Fort Collins is listed as an additional insured under the cyber/network security coverage (endorsement is pending.) Notice of cancellation will be provided to certificate holder for non -renewal and cancellations on the auto, general liability/professional liability, and excess liability policies. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD -om:Amy Merritt Fax ID:HBInsuranceGroup Date:2/24/2016 12:05:27 PM Page: 5 of 6 Healthcare Facilities Primary .,o. r u (I , P, rt E rIS,3r:,..iTteFit ................ . rips AO'bi lbrilAL The changes set forth below are applicable only to coverage parts included within the scope of this endorsement. The coverage parts included within the scope of this endorsement are indicated by a check mark. LX Professional Liability Coverage Part L? General Liability Coverage Part It is understood and agreed as follows: SCHEDULE ............... Name Of Additional Insured Person Or Organization C&S Wholesale Grocers, Inc., 10 Optical Avenue, Keene, NH 03431 CEBT, 2000 South Carolina Blvd, Tower 11, Suite 900, Denver, CO 80222 CHG Healthcare Services, 6440 South Millrock Drive, Suite 175, Salt Lake City, UT 84121 _ ........ ........ Chico's FAS, Inc. 11215 Metro Parkway, Fort Myers, FL 33901 City of Fort Collins, 214 N Howes Street, Fort Collins, CO 80521 City of Fort Lauderdale, Procurement Services Division, 100 N Andrews Ave Room 619, Fort Lauderdale, FL 33301 Great West Life & Annuity Insurance Company, 8515 E Orchard Road, Greenwood Village, CO 80111 Keller Independent School District, 5308 Tarrant Parkway, Keller, TX 76244 ........................... ........... ............................. ......................... .......................................... ............................... ..................... ...................................... ......................................................... ........... ................. ......................... .......................................... ... .......................... ................................................. ............ ........... ....i New Boston AtlanTech, LP, 6451 North Federal Highway, Suite 112, Fort Lauderdale, FL 33308 ...... ........... . _ ......... ......... ..... . ........................ ........ . ................. .......... ... .... ......... ........................ _........................... ............. ; The City of St. Cloud, Insurance Compliance, PO Box 12010-OD, Hemet, CA 92546-8010 ............. ..................................................................................._.................................................................................................................._.............................._......................................................................._................................................................... Trustmark National Bank, 248 East Capitol Street, Jackson, MS 39201 Wake County, 337 South Salisbury Street, Raleigh, NC 27601 ... ................. ..... .. ..... .............................. . . ... Widefield School District #3, 930 Leta Drive, Colorado Springs, CO 80911 I. The definition of Insured in the GLOSSARY OF DEFINED TERMS is amended as follows: Solely with respect to the General Liability Coverage Part, Insured also means the person or organization shown in the SCHEDULE above, but such person or organization is an Insured exclusively for bodily injury or property damage arising out of an occurrence, or personal and advertising injury arising out of an offense, for which such person or organization is vicariously liable because of acts or omissions committed by the Insured Entity: A. in the performance of the Insured Entity's ongoing operations; or B. in connection with premises owned by or rented to the Insured Entity. There is no coverage for such person or organization for bodily injury, property damage, or personal and advertising injury arising out of its own acts or omissions. ........ i Form No: CNA71913XX (03-2013) Policy No: HMA 1064390164-10 Endorsement Effective Date: Policy Effective Date: 01 /19/2015 Endorsement No: 15; Page: 1 of 2 Policy Page: N/A i Underwriting Company: Columbia Casualty Company, 333 S. Wabash Ave., Chicago, IL, 60604 e Copyright CNA All Rights Reserved. -om:Amy Merritt FaxID:HBInsuranceGroup Date:2/24/2016 12:05:27 PM Page: 6 of 6 CNA Healthcare Facilities Primary Coverage Part. i:::ndQrSe'Tterst If the Professional Liability Coverage Part is included within the scope of this Endorsement, as indicated by a check mark above, then, solely with respect to the Professional Liability Coverage Part, Insured also means the person or organization shown in the SCHEDULE above, but such person or organization is an insured exclusively for the vicarious liability imposed upon such person or organization because of acts, errors or omissions in the rendering of covered professional services by the Insured Entity. There is no coverage for such person or organization for its liability arising out if its own acts, errors or omissions. The coverage afforded under this endorsement shall be subject to all other terms and conditions of this policy. Nothing herein shall serve to confer any rights to such person or organization under this policy other than as provided herein. In no event shall the inclusion of such person or organization as an Insured operate to increase the Limits of Insurance stated on the Declarations and provided under this policy. All other terms and conditions of the policy remain unchanged. This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy. ..................... .................. ......... _..................................... _................... ......._............_.............. ........... ............... ........................... _....._._.............._......................................_...................... _......... Form No: CNA71913XX 103-20131 Policy No: HMA 1064390164-10 Endorsement Effective Date: Policy Effective Date: 01/19/2015 Endorsement No: 15; Page: 2 of 2 Policy Page: N/A Underwriting Company: Columbia Casualty Company, 333 S. Wabash Ave., Chicago, IL, 60604 t Copyright CNA All Rights Reserved.