Loading...
HomeMy WebLinkAbout541195 MARATHON HEALTH INC - INSURANCE CERTIFICATE (3)ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MARAHEA-01 AMERRITT 0 1 1 Marathon Health, LLC d/b/a Marathon Health 20 Winooski Way, Suite 400 Winooski, VT 05404 Hickok & Boardman, Inc. SEE PAGE 1 SEE PAGE 1 SEE P 1 SEE PAGE 1 ACORD 25 Certificate of Liability Insurance Description of Operations/Locations/Vehicles: 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. Healthcare Facilities Primary Coverage Part Endorsement ADDITIONAL INSURED ENDORSEMENT 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. Professional Liability Coverage Part General Liability Coverage Part It is understood and agreed as follows: SCHEDULE Name Of Additional Insured Person Or Organization X X City of Fort Collins, 214 N Howes Street, Fort Collins, CO 80521 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. HMA 1064390164-10 Endorsement No: 15; Page: 1 of 2 Policy Page: N/A Underwriting Company: Columbia Casualty Company, 333 S. Wabash Ave., Chicago, IL, 60604 Form No: CNA71913XX (03-2013) Endorsement Effective Date: Policy No: Policy Effective Date: 01/19/2015 © Copyright CNA All Rights Reserved. Healthcare Facilities Primary Coverage Part Endorsement II. 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. 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. All other terms and conditions of the policy remain unchanged. HMA 1064390164-10 Endorsement No: 15; Page: 2 of 2 Policy Page: N/A Underwriting Company: Columbia Casualty Company, 333 S. Wabash Ave., Chicago, IL, 60604 Form No: CNA71913XX (03-2013) Endorsement Effective Date: Policy No: Policy Effective Date: 01/19/2015 © Copyright CNA All Rights Reserved. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 01/06/2017 (802) 383-1657 (802) 658-0541 31127 Marathon Health, LLC d/b/a Marathon Health 20 Winooski Way, Suite 400 Winooski, VT 05404 37478 41718 A 5,000,000 X HMA 1064390164-11 01/19/2017 01/19/2018 100,000 5,000 5,000,000 5,000,000 5,000,000 B 1,000,000 04 SBA UK8133 SB 01/19/2017 01/19/2018 A 5,000,000 X HMC 4031941072-4 01/19/2017 01/19/2018 5,000,000 C 04WECCF8560 01/19/2017 01/19/2018 500,000 500,000 500,000 A Medical Prof Liab HMA 1064390164-11 01/19/2017 Claims Made Coverage 5,000,000 D Cyber Liability X PRO10008507700 01/19/2017 01/19/2018 Limit 5,000,000 Named insured includes, Marathon Health, LLC, Marathon Health Holdings, Inc., MH 101, PC, MH 102, 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 excess policy follows form, including additional insured status.) City of Fort Collins is listed as an additional insured under the cyber/network security SEE ATTACHED ACORD 101 City of Fort Collins 300 LaPorte Ave Fort Collins, CO 80521 MARAHEA-01 AMERRITT Hickok & Boardman, Inc. 346 Shelburne Rd Burlington, VT 05401 Amy Merritt amerritt@hbinsurance.com Columbia Casualty Co Hartford Casualty Ins Co Hartford Ins Co of the Midwest Endurance American Specialty Ins Co X 01/19/2018 X X X X X X X