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HomeMy WebLinkAboutC16-476 Natalie Bullard DVMSponsored by Veterinary Professional Liability Insurance Policy Amended Certificate of Insurance This policy provides occurrence coverage. Please review the policy carefully. ITEM 1: Insured by the stock company below and hereinafter called the Company Zurich American Insurance Company U-VPL-103-A-CW (07/04) ITEM 2:Named Certificate Holder, member number, IRC, and address Master Policy Number:Certificate Number: EOL 5241302 -12 VETPRO077305 FOR INFORMATION OR TO FILE A CLAIM PLEASE CALL (800) 228-7548 ITEM 3: Policy Period From:01/01/2017 To:01/01/2018 12:01 am Standard time at the address of the Named Certificate Holder as stated herein Natalie Ann Bullard, DVM PO Box 3085 Eagle, CO 81631-3085 ITEM 4: Limits of Liability Member Name Member No.IRC Class Each claim $ 1,000,000 Natalie Bullard 217614 17 IV Aggregate $ 3,000,000 ITEM 5:Premium and coverage summary ITEM 6: Forms Attached at Issuance: U-VPL-100-A CW (07/04); U-VPL-103-A CW (07/04); U-GU-1041-A (03/11); U- VPL-126-A CO (09/04); U-GU-319-F (01/09) ITEM 7: Schedule of Plan Numbers and location(s) for Professional Extension Endorsement (Animal Bailee) / Embryo and Semen Storage (if purchased): For additional locations, please see the attached page Primary Professional Liability TOTAL DUE: $238.00 $238.00 Location Number/Address Extension Plan Embryo Plan ITEM 8:Veterinary Professional Liability Regulatory Action License Defense Coverage endorsement (if purchased): Limit: Authorized Signature Neil R. Hughes, President HUB International Midwest Limited This Certificate of Insurance is issued off the Master Policy held by the American Veterinary Medical Association (AVMA) Professional Liability Insurance Trust. By acceptance of this policy the Named Certificate Holder agrees that the statements in the certificate and the application and any attachments hereto are the Named Certificate Holder’s agreements and representations and that this policy embodies all agreements existing between the Named Certificate holder & the Company or any of its representatives relating to this insurance. Notice to the Company:Zurich North American-Specialties Claims Attn: Professional Liability Claim Department P.O. Box 307010, Jamaica, NY 11430-7010 Advisory notice to policy holders regarding the U.S. Treasury Department’s Office of Foreign Assets Control(“OFAC”) regulations. U-GU-1041-A (3/11) Page 1 of 1 Title of form must not be placed above the logo ↑ Top Margin 3/4" No coverage is provided by this policyholder notice nor can it be constructed to replace any provisions of your policy. You should read your policy and review your declarations page for complete information on the coverages you are provided. This notice provides information concerning possible impact on your insurance coverage due to directives issued by the U.S. Treasury Department’s Office Assets Control (“OFAC”). Please read this Notice carefully. OFAC administers and enforces sanctions policy based on Presidential declarations of “national emergency”. OFAC has identified and listed numerous: Foreign agents; Front organizations; Terrorists Terrorists organizations; and Narcotic traffickers; as “Specially Designated Nationals and Blocked Persons.” This list can be located on the United States Treasury’s web site – http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx. In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this insurance will be considered blocked or frozen contract and all provisions of this insurance are immediately subject to OFAC restrictions. When an insurance policy is considered to be such a blocked or frozen contract, no payments or premium refunds may be made without authorization from OFAC. Other limitations on premiums and payments also apply. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Endorsement # Colorado Amendatory Endorsement U-VPL-126-A CO (09 / 04) Page 1 of 2 Title of form must not be placed above the logo ↑ Top Margin 3/4" Master Policy No.Certificate No.Eff. Date of Cert.Exp. Date of Cert.Eff. Date of End.Add’l Prem.Return Prem. EOL 5241302 -12 VETPRO077305 01/01/2017 01/01/2018 01/01/2017 $0.00 $0.00 Named Certificate Holder and Mailing Address: Natalie Ann Bullard, DVM PO Box 3085 Eagle, CO 81631-3085 Producer: HUB International Midwest Limited 55 East Jackson Boulevard Chicago, IL 60604-4187 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Veterinary Professional Liability Insurance Policy It is agreed that Section IV – CONDITIONS, Paragraph D is deleted in its entirety and replaced with the following: 1.CANCELLATION a.This policy may be canceled by the Named Certificate Holder by surrender of the policy to the Company or by mailing written notice to the Company stating when such cancellation shall take effect. If canceled by the Named Certificate Holder, the Company shall retain the customary short-rate proportion of the premium. In no event may the requested date of cancellation be greater than ten (10) days prior to the date the request is received by the Company. b.This policy may be canceled by the Company by mailing written notice by certified mail or first class mail to the Named Certificate Holder at the address shown in the Certificate of Insurance. Such cancellation shall be no fewer than forty-five (45) days from the date the notice is mailed unless the policy is canceled because the Named Certificate Holder has failed to pay a premium. In that event, such cancellation shall take effect no fewer than ten (10) days from the date the notice is mailed. The Company may cancel this policy for the following reasons: (1)Nonpayment of premium; (2)A false statement knowingly made on the application for insurance; or (3)A substantial change in the exposure or risk from what was indicated on the application and underwritten as of the effective date of the policy unless the Named Certificate Holder has notified the Company of the change and the Company accepts such change. If the policy is canceled by the Company, the earned premium shall be computed pro-rata. Premium adjustment may be made at the time cancellation is effected or as soon as practicable thereafter but not more than forty-five (45) days after the effective date of cancellation by the Company or after the date of entitlement established by notification of cancellation or as otherwise established. Failure to pay any premium adjustment at, on, or around the time of the effective date of cancellation shall not alter the effectiveness of cancellation. 2.NONRENEWAL a.If the Company elects not to renew this policy, the Company will mail by certified mail or first class mail to the Named Certificate Holder at the address shown in the Certificate of Insurance, and mail to the producer of record, if any, written notice of nonrenewal at least forty-five (45) days prior to the expiration of this policy. b.If notice is mailed, proof of mailing will be sufficient proof of notice. c.If either one of the following occurs, the Company is not required to provide written notice of nonrenewal: (1)the Company or another Company within the same insurance group has offered to issue a renewal policy; or the Named Certificate Holder has obtained replacement coverage or agreed in writing to do so. U-VPL-126-A CO (09 / 04) Page 2 of 2 3.CONDITIONAL RENEWAL a.If the Company elects to renew this policy and the renewal is subject to any of the following: (1)Increase in premium; (2)Reduction in Limit of Liability; or (3)Reduction in coverage; the Company shall mail by certified mail or first class mail written notice of the change(s) to the Named Certificate Holder, at the address shown in the Certificate of Insurance and the producer of record, if any, at least forty-five (45) days before the anniversary or expiration date of the policy. b.If renewal is subject to any condition described in a(1) through a(4) above, and the Company fails to provide notice forty-five (45) days before the anniversary or expiration date of this policy, the following procedures apply: (1)the present policy will remain in effect until the earlier of the following: (a)Forty-five (45) days after the date of mailing or delivery of the notice; or (b)The effective date of replacement coverage obtained by the Named Certificate Holder. (2)If the Named Certificate Holder elects not to renew, any earned premium for the period of extension of the terminated policy will be calculated pro rata at the lower of the following rates: (a)The rates applicable to the terminated policy; or (b)The rates presently in effect. c.If the Named Certificate Holder accepts the renewal, the premium increase, if any, and other changes are effective the day following this policy's anniversary or expiration date. All other terms, conditions and exclusions of this policy remain unchanged. 12/29/2016Signed by: Date Authorized Representative U-GU-1147-A (01/14) Page 1 of 2 Fraud Warnings Disclosure TO BE ATTACHED TO AND FORM PART OF THE APPLICATION. IF FRAUD WARNINGS ARE INCLUDED IN THE APPLICATION TO WHICH THIS IS ATTACHED, THIS DISCLOSURE REPLACES THOSE WARNINGS. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA, and WV.) In Arkansas, Louisiana, Rhode Island, or West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. In Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. In District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. In Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. In Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to an insurer, purported insurer, or to or by a broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act and may be subject to criminal and/or civil fines or penalties. In Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. In Maine, Tennessee, Virginia, or Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. U-GU-1147-A (01/14) Page 2 of 2 In Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. In New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. In New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. In Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. In Oregon: Any person who knowingly and with intent to defraud any insurer or other person files an application for insurance or statement of claim containing any materially false information upon which an insurer relies, if such information was either material to the risk assumed by the insurer or the misinformation was provided fraudulently, may commit a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. In Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Puerto Rico: Any person who has committed fraud, as defined in the law, shall incur a felony, and if convicted, shall be sanctioned for each violation by a penalty of a fine of not less than five thousand dollars ($5,000), nor more than ten thousand dollars ($10,000), or a penalty of imprisonment for a fixed term of three (3) years, or both penalties. If there were aggravating circumstances, the fixed penalty thus established may be increased up to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. In addition to the penalties provided in this chapter, any person who, as a result of the fraud thus committed is benefited in any way to obtain insurance, or in the payment of a loss pursuant to an insurance contract, shall be imposed the payment of restitution of the amount of money resulting from the fraud. Every violation shall have a prescription term of (5) five years. In Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. The undersigned, on behalf of all Insureds, acknowledges that discovery of any fraud, intentional concealment, or misrepresentation of any material fact may render this policy, if issued, voidable at inception or otherwise cancelled. Applicant Applicant Name and Title:Natalie Ann Bullard, DVM Date:01/01/2017 Applicant Signature: Important Notice to Policyholders U-GU-1194-A CW (08/15) Page 1 of 1 The address for the headquarters of Zurich North America will change after August 1, 2016 due to a relocation of our office in the same city. The new address is: Customer Inquiry Center Zurich North America 1299 Zurich Way Schaumburg, IL 60196 1-800-382-2150 For specific questions regarding your policy, please contact your agent or broker. For other questions, you may contact the Customer Inquiry Center of Zurich North America. Any references to post office boxes previously provided remain unchanged. FORMAT IS A SAMPLE OF A BLANK FORM