HomeMy WebLinkAboutCOLUMBINE MANAGEMENT SERVICES / COLUMBINE HEALTH - INSURANCE CERTIFICATEACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY)
♦��1 6/29/2018
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 CONTACT NAME: Donna Birleffi
Professional Risk LLC PHONE,
(970) 356-8030 - TA Nolc (970)356-8032
8213 W.20th St E-MAJLs:donna.birleffi@proriskllc.com
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INSURER(S) AFFORDING COVERAGE NAIC N
Greeley CO 80634 INSURERA:HealthCap RRG
INSURED INSURERS:Travelers Commercial Cas Co 25674
Columbine Management Services, Inc. dba INSURERC:State National Insurance
Columbine Health Systems INSURER0:
802 West Drake Road, Suite 101 INSURERE:
Fort Collins CO 80526 INSURERF:
rnVFaAr'_Fs rFRTIFIrATF NI IMRFP-18-19 Management -All 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.
INSR ! SUBR
AINSD DDL
POLICY EFF 7 POLICY EXP
LTR I TYPE OF INSURANCE POLICY NUMBER
MM/DD/YYYY M/D LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR
X_ Professional Liability_
X HRG-CO01-0001-OC-15
7/1/2018 7/1/2019
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISESSEa-occurrence
MED EXP (Any one person)
$ 1,000,000
$ 100,000
$ 5,000
PERSONAL 8 ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 3,000,000
PRO
JECTnLOC
PRODUCTS-COMP/OPAGG
3,000,000POLICY
$
Employee Benefits
_
$ 1,000,000
OTHER.
AUTOMOBILE LIABILITY
N N L IMrr
( aaccint
$ 1,000,000
ANY AUTO
FX
BODILY INJURY (Per person)
$ALL
OWNED j SCHEDULED BA5E978078
7/1/2018 7/1/2019 BODILY INJURY (Per accident)
$
,AUTOS AUTOS
NON -OWNED
PROPERTY DAMAGE
$
HIRED AUTOS j AUTOS
(Per accident) _
Uninsured motorist combined
$ 1,000,000
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
$
DED ' RETENTION $
C WORKERS COMPENSATION
'IAND EMPLOYERS' LIABILITY
PERJ( -
STAB. _. ER
I__-
E.L. EACH ACCIDENT
$ 1 000-, 000
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
NDE092771718 1/1/2018 1/1/2019
OFFICER/MEMBER EXCLUDED? N / A
---
(Mandatory in NH)
E.L. DI ISEASE - EA EMPLOYE
$ 1,000,000
E.L DISEASE - POLICY LIMIT
$ 1,000,000
If -
yes. describe under
DESCRIPTION OF OPERATIONS below
I
i
I
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Fort Collins, a Municipal Corporation is
listed as additional insured as pertains to the
General Liability policy, per written contract.
CERTIFICATE HOLDER UANt:tLLAIIVN
The City of Fort Collins, a Municipal
Corporation
Attn: Bob Adams, Director of Purchasing
and Risk Management
PO Box 580
Fort Collins, CO 80522
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
ionne Perez/DP
U 19BU-2014 ACORD COKPUKA I ION. All rlgnts reservea.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)