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HomeMy WebLinkAbout482592 POUDRE VALLEY HEALTH SYSTEM - INSURANCE CERTIFICATE (3)oRo® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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). CONTACT PRODUCER Beecher Carlson Insurance Services, LLC NAME, 321 North Clark Street, 5th Floor PHONE FAX [(A/C. No. Extl, I Chicago, IL 60654 E-MAIL A/CNo: INSURED Poudre Valley Health Care, Inc. d/b/a Poudre INSURER B : Travelers Property Casualty Co of Amer 25674 Valley Health System and Poudre Valley Hospital INSURERC: 2315 E. Harmony Rd., Suite 200 INSURER D: Travelers indemnity Company 25658 Fort Collins CO 80528 INSURERE: INSURER F : rOVFRAr;FS CERTIFICATE NIIMRFR• �onianno Dcvl clnkl kIIIAMIDCD. 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 ADDLISUBR� TYPE OF INSURANCE INSD VIVI1 POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ CLAIMS -MADE - OCCUR 'HCCO013228 10/1/2017 10/1/2018 EACHOCCURRENCE $ 1,000,000 DAMAGE T RENTE PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY PRO- ❑✓ LOC GENERAL AGGREGATE $ 3,000,000 GEN'L ✓ PRODUCTS - COMP/OP AGG $ 1,000,000 $ OTHER: B AUTOMOBILE LIABILITY TJCAP4251B599-TIL-17 10/1/2017 10/1/2018 CEOMaBI�dEDtSINGLELIMIT $ 1000000 BODILY INJURY (Per person) $ ✓ ANY AUTO 1 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LIAR DIED I I RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N AN7PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? FYI N/A TC2KUB 17616963-17 Aggregate$15,061,199 10/1/2017 10/1/2018 STATUTE ORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) f Iyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Health Care Professional Liability HCC0013228 10/1/2017 10/1/2018 Per Claim: $1,000,000 Aggregate: $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Fort Collins is listed as an additional insured with respect to General Liability only. Professional liability limits include errors and omissions coverage. VCR I Irm m I r- r1ULULR t ANL tLLA I IUIV City of Fort Collins Risk Management Occuppational Health 215 N. Mason Fort Collins CO 80524 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 �y!l '7 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 38015092 1 17-18 GL PL, AD UMB WC (Poudre I (PROV) Denise Simmons 19/27/2017 10:20:52 AM (EDT) I Page 1 of 1