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HomeMy WebLinkAboutTHE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY - INSURANCE CERTIFICATEACOR"s CERTIFICATE OF LIABILITY INSURANCE I /l/2017 DATE(MM/DDNYYY) 12/23/2015 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 LOCKTON COMPANIES 5500 Wayzata Blvd., Suite 510 Minneapolis MN 55416 763-512-8600 NAME: PHONE A/c, Ext : A/C, No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A : Sentry Insurance a Mutual Company 24988 INSURED THE EVANGELICAL LUTHERAN GOOD 1322557 SAMARITAN SOCIETY 4800 WEST 57TH STREET SIOUX FALLS, SD 57108 INSURER B : INSURER C INSURER D : INSURER E : INSURER F : COVERAGES FVALIl01 CERTIFICATE NUMBER_ 1 1 1(S1I SO'i RF\iISInN NHMRFR• XXXXXXX 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 SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y N 90-04424-09 1/1/2016 1/1/2017 EACH OCCURRENCE 1,000,000 CLAIMS -MADE OCCUR PREMISESa occurrence 500,000 X MED EXP (Any oneperson) $ XXXXXXX INCLUDES PROF.LIAB. PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRCO-- FLOC GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ Included $ OTHER A AUTOMOBILE LIABILITY N N 900442402 1/1/2016 1/I/2017 Ea BBINED1SINGLE LIMIT $ 1,000,000 X BODILY INJURY (Per person) $ XXXXXXX ANY AUTO AUTOWNED SCHEDULED BODILY INJURY (Per accident $ XXXXXXX HIRED AUTOS NON -OWNED PROPERTY acidetDAMAGE $ XXXXXXX $XXXXXXX UMBRELLA LIAB OCCUR EACH OCCURRENCE $ XXXXXXX EXCESS LIAB NOT APPLICABLE HCLAIMS-MADE AGGREGATE $ XXXXXXX DED I I RETENTION $ $ A A WORKERS COMPENSATION AND Y/N AN OFFICER MEMBERlEXCLUDED? ECUTIVE N❑ N / A N 900442401 AOS) 900442404 (HI, WI) 1/1/2016 1/1/2016 I/1/2017 1/1/2017 PER OTH- X STATUTE FIR E.L. EACH ACCIDENT $ 2 000 000 E.L. DISEASE - EA EMPLOYEE 2,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached if more space is required) TEXAS FACILITIES ARE NON -PARTICIPATING 1N WORKERS COMPENSATION. #0870 GOOD SAMARITAN SOCIETY - FORT COLLINS VILLAGE; FORT COLLINS, CO. THE CITY OF FORT COLLINS IS INCLUDED AS ADDITIONAL INSURED WITH RESPECTS TO GENERAL LIABILITY, REGARDING THE 5K WALK/RUN EVENT TAKING PLACE ON APRIL 25, 2015. 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. 13381803 AUTHORIZED REPRE CITY OF FORT COLLINS FINANCIAL SERVICES RISK MANAGEMENT 215 N. MASON ST., 2ND FLOOR PO BOX 580 FORT COLLINS, CO 80522 ACORD 25 (2014/01) ©1 : y 1_�41 4 ACORD CORPORATION- All riahts reservPrl The ACORD name and logo are registered marks of ACORD