HomeMy WebLinkAboutCOLUMBINE HEALTH SYSTEMS - INSURANCE CERTIFICATE (7)AC")?" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
�./ 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
8213 W.20th St
PHONE (970)356-8030 FAX (970)356-8032
(A/C, No, Ext) --- - (A/C
ADDRESS: donna. birleffi@proriskllc . com
INSURER((�AFFORDING COVERAGE
Greeley CO 80634 INSURERA_Health_ CapRRG_..______
INSURED INSURERB:Travelers Commercial Cas CO 25674
Columbine Management Services, Inc. dba INSURERC:State National Insurance
Columbine Health Systems INSURERD:
802 West Drake Road, Suite 101 INSURERE:
Fort Collins CO 80526 INSURER F :
/100TI1CIn ATC 6I1 IRA11211=0•1 R-1 Q Ma Aar mant-A11 RFVISIr)N NI IMRFR-
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.
ADDLSUBR'— - ---_
__ PQLICYEFF' POLICY EXP LIMITS
LTR I TYPE OF INSURANCE INSD WVD POLICY NUMBER
M MM/DD/YYYY
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
1,000,000
A
���
CLAIMS -MADE OCCUR
I
DAMAGE TO RENTED
PREMISES Laoccurrence
$
100,000
$
5,000
X Professional Liability
X
HRG-CO01-0001-OC-15
7/1/2018 7/1/2019
MED EXP (Any one person)
PERSONAL & ADV INJURY
$
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$
3,000,000
PRODUCTS - COMP/OP AGG
$
3, 000 , 000
POLICY �) PRO n LOC
JECT
—------
Employee Benefits
$
1,000,000
OTHER.
AUTOMOBILE LIABILITY �,I
CO INED SINGLE LIMIT
(Ea accdent)__ $
1,000,000
X ANY AUTO
BODILY INJURY (Per person) $
B
ALL OWNED SCHEDULED BA5E978078
- --
7/1/2018 7/1/2019 BODILY INJURY (Per accident ) $
AUTOS AUTOSX
_ AUTOS AUTOS
NON -OWNED
PROPERTY DAMAGE $
F, HIRED AUTOS AUTOS
(Per accident)
Uninsured motorist combined $
1,000,000
UMBRELLA LIAB OCCUR
EACH OCCURRENCE _ $
EXCESS LIAB CLAIMS_ -MADE
AGGREGATE -$
DED RETENTION $
$
C IWORKERS COMPENSATION
STATUTE X ER
A
IAND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
NDE092771718
1/1/2018 1/1/2019
-- - - -
$
- -
1D? 000 000
- -
E.LEACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
OFFICER/MEMBER EXCLUDENIA
,(Mandatory in NH)
$
1,000,000
E.L. DISEASE -POLICY LIMIT
$
1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: License C1-8. City of Fort Collins is listed as
additional insured as pertains to the General
and
Auto Liability policies, per written contract.
CEKTIFICA I E HULUEK I+M IY IiCLLM I KJIY
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
Dionne Perez/DP
U 19t5S-ZU14 AGUKLI UUKI'UKA I IUrv. All rlgnTs reserveu.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)