HomeMy WebLinkAboutC18-346 Mountain Family Health Services1 June 18 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 EAGLE COUNTY DREL J E BEL R D SOPRIS VILLAGE DRVALLEY RDZ0255012.5Feet1 inch = 30 feetMSCEl Jebel AreaMobile Dental Unit DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD C1SCARTMELL Shanti Cartmell, CIC 05/31/2018 MOUNFAM-01 B USO(19)56117851 A BAS(19)56117851 C 1461272 A BZS(19)56117851 D PHSD1254416 1,000,000 1,000,000 1,000,000 10,000 2,000,000 2,000,000 2,000,000 1,000,000 2,000,000 15,000 1,000,000 1,000,000 1,000,000 XX X X X X X X X X X E 106315312 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2021 Certificate Holder is included as Additional Insured with regard to General Liability & Business Auto and ongoing operations of the insured as required by contract. AssuredPartners Colorado4582 S. Ulster Street Suite 600 Denver, CO 80237 (970) 945-5593 Eagle County PO Box 660 Eagle, CO 81631 Mountain Family Health Centers PO Box 339 Glenwood Springs, CO 81602 Ohio Security Insurance Co. Ohio Casualty Insurance Company Pinnacol Assurance Philadelphia Indemnity Company Travelers Casualty & Surety Co of America 31194 24082 24074 18058 41190 X X shanti.cartmell@assuredpartners.com N Deductible $5,000 Deductible $2,000 1,000,000 200,000 Directors & Officers Crime DocuSign Envelope ID: 6E5250D1-59A6-4BA6-A4E4-0DB2A574C083