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HomeMy WebLinkAboutCORRESPONDENCE - FAX QUOTE - 8637 DOT MEDICAL EXAMS (2)Occupational Health Centers of the Southwest, P.A., d/b/a DocuSign Envelope ID: 00944A09-2DF0-4E70-B687-5C61ECB5F3A1 12/6/2019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ PROPERTY DAMAGE $ BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: CONCGRO-01 1 1 The Graham Company Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 25 CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-5; Effective 10/1/2019-10/1/2020 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-5; Effective 10/1/2019-10/1/2020 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-5; Effective 10/1/2019-10/1/2020 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-5; 10/1/2019-10/1/2020 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-5; 10/1/2019-10/1/2020 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Policy #WA5-63D-510199-319; Effective: 10/1/2019-10/1/2020 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Policy #WA7-63D-510199-409 and WC7-631-510199-259; Effective: 10/1/2019-10/1/2020 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas – Policy #WC7-631-510199-289; Effective: 10/1/2019-10/1/2020 OHC of Southwest (AZ/UT) – Policy #WC2-631-510199-249; Effective: 10/1/2019-10/1/2020 OHC of Delaware – Policy #WC2-631-510199-339; Effective: 10/1/2019-10/1/2020 OHC of Georgia/Hawaii – Policy #WC2-631-510199-389; Effective: 10/1/2019-10/1/2020 OHC of Illinois – Policy #WC2-631-510199-419; Effective: 10/1/2019-10/1/2020 OHC of Louisiana – Policy #WC2-631-510199-299; Effective: 10/1/2019-10/1/2020 OHC of Michigan – Policy #WC2-631-510199-279; Effective: 10/1/2019-10/1/2020 OHC of Nebraska – Policy #WC2-631-510199-379; Effective: 10/1/2019-10/1/2020 OHC of New Jersey – Policy #WC2-631-510199-269; Effective: 10/1/2019-10/1/2020 OHC of North Carolina – Policy #WC7-631-510199-349; Effective: 10/1/2019-10/1/2020 OHC of Southwest (KS) – Policy #WC2-631-510199-429; Effective: 10/1/2019-10/1/2020 Therapy Centers of Southwest I, PA (OR) - Policy #WC2-631-510199-399; Effective: 10/1/2019-10/1/2020 Therapy Centers of South Carolina, PA - Policy #WC2-631-510199-309; Effective: 10/1/2019-10/1/2020 OHC of Minnesota - Policy #WC2-631-510199-459; Effective: 10/1/2019-10/1/2020 OHC of Alaska - Policy #WC2-631-510199-449; Effective: 10/1/2019-10/1/2020 CYBER LIABILITY - National Union Fire Insurance Company of Pittsburgh, PA - Policy #01-950-31-88; Effective 9/25/2019-2020 - Limit: $10,000,000 Security and Privacy EXCESS CYBER LIABILITY - Endurance American Insurance Company - Policy #PRX10009889402; Effective: 9/25/2019-2020 - Limit: $10,000,000 Each Occurrence/Aggregate Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed for or on behalf of the above Named Insured. RE: OHC-SWPA/CMC HAS AN AGREEMENT UNDER # RQ8637 TO PROVIDE DOT MEDICAL EXAMS TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF FORT COLLINS IS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY, AUTOMOBILE LIABILITY AND EXCESS LIABILITY COVERAGES IF REQUIRED BY WRITTEN CONTRACT. (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER (MM/DD/YYYY) LIMITS POLICY EXP (MM/DD/YYYY) POLICY EFF LTR TYPE OF INSURANCE POLICY NUMBER INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $ $ OCCUR CLAIMS-MADE DED RETENTION $ PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $ EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 9/30/2019 The Graham Company The Graham Building 1 Penn Square West Philadelphia PA 19102- Concentra Unit 215-567-6300 215-405-2694 Concentra_Unit@grahamco.com Columbia Casualty Company 31127 CONCGRO-01 American Guarantee & Liability Ins. Co. 26247 Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 Liberty Mutual Fire Ins. Co. 23035 Allied World Assurance Company, LTD Liberty Insurance Corporation 42404 Liberty Mutual Insurance Group 23043 417338512 A X 1,000,000 X 500,000 X Professional Lia 10,000 X $1M Claim/$3M Ag 1,000,000 3,000,000 X Y HAZ 4032244581-4 10/1/2019 10/1/2020 3,000,000 C 2,000,000 X Y AS2-631-510199-329 10/1/2019 10/1/2020 A X X HMC 4032235752-4 10/1/2019 9,000,000 Y 10/1/2020 10,000,000 X 3,000,000 E F WA7-63D-510199-359 X WC5-631-510199-369 10/1/2019 10/1/2019 10/1/2020 10/1/2020 1,000,000 1,000,000 1,000,000 B D Property Excess Liability ZMD0119116-04 C023701-005 6/1/2019 10/1/2019 10/1/2020 10/1/2020 SEE BELOW $10M Each Occurrence $10M Aggregate UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $3,000,000 Self-Insured Retention each Occurrence/Claim subject to a $10,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-5; Effective 10/1/2019-10/1/2020 - $400,000 Each Medical Incident/$1,200,000 Aggregate Per Insured or Surgeon See Attached... CITY OF FORT COLLINS PO BOX 580 ATTN: PURCHASING DIRECTOR FORT COLLINS CO 80522