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HomeMy WebLinkAbout543224 SUMMITSTONE HEALTH PARTNERS - INSURANCE CERTIFICATE (2)7627/2018 (MWDD/YYYY) A`COR" CERTIFICATE OF LIABILITY INSURANCE 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 '00—NTACT Donna Birleffi NAME: Professional Risk LLC PHONE (970) 356-8030- - AX No): (970) 356 -8032 8213 W.20th St E-MAIL donna.birleffi@proriskllc.com ADDRESS: -------_-. .-_------------------- INSUREWS) AFFORDING COVERAGE NAIC N Greeley CO 80634 INSURERA:Philadelphi INSURED INSURERB:Pinnacol As SummitStone Health Partners INSURERC:Travelers C 125 Crestridge Street INSURERD: Co Fort Collins CO 80525 I INSURERF: rnVFRAr.FR CFRTIFICATF NI)MRFR-18-19 All REVISION NUMBER: 194 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. ILT R TYPE OF INSURANCE ADDL SUER POLICY NUMBER PM! ICY EFF POLICY EXP LIMITS LTRWvp X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I DAMAGES (RENTED 100,000 A CLAIMS -MADE _X_ OCCUR Xi O � i PREMISES Ea occurrence $ _ $ 5,000 X Professional - -._ _ - X PHPK1842922 7/1/2018 7/1/2019 I MED EXP (Any one person) PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 3,000,000 POLICY PRO X LOC JECT — Prof Liab Aggregate $ 3,000,000 OTHER: AUTOMOBILE LIABILITY COMBINEDN _LEa accident _ $ 1,000,000 $ X ANY AUTO BODILY INJURY (Per person) A - T SCHEDULED _ ALL OOWNED �� AUTOS X I - - - BODILYINJURY PHPK1842922 7/1/2018 7/1/2014 BODILY INJURY (Per accident) --- -- S $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS J AUTOS (Per accident)--- $ 1,000,000 Uninsured motorist combined UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ _ CLAIM -MA _ EXCESS LIARETEN710N - _ $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 4044330 7/1/2018 7/1/2019 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below I C Privacy 106545865 7/1/2018 7/1/2019 Eachlnc/Agg 2,000,000 A HIPAA PHSD1360018 7/1/2018 7/1/2019 'Limit 50,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Fort Collins is listed as additional insured as pertains to the General and Auto Liability policies, per written contract. CERTIFICATE HOLDER CANCELLATION City of Fort Collins 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 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)