HomeMy WebLinkAboutInsurance Certificate: Ashland Community Healthcare Srvcs
DATE (MMIDOM'YY)
°RO® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 01/30/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
BELOW CTH S CERTIFICATE FIN INSURANCE DOES N NEGATIVELY OT CONSTITUTE A CONTRACT BETWEEN OTHERISSUING INSURER(S), AU HOR ZIED
CETIFIATE DOES NOT AFFIRMATIVELY OR 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).
coNTACT
PRODUCER
Willis management (vermonU Ltd. PHONE 800-5__88-061_9 aL, 713-243-7350
c/o 26 century Blvd. U--
E-MAIL
P. 0. Box 705191 LED
Nashville, TN 37230-5191 INSURER(S)AFFOftOING COVERAGE NAICW
INSURERAA: Mountain States Healthcare (BRAG) R2532-001
INSURED Idl_yllSa
Y-----
Ashland Cowouni ty Healthcare services (dha Ashlan 1 Sa e¢e
11
280 Maple street NSURER C. _
Ashland, OR 97520 rINSURERD:
INSURER E'
INSURER F'.
COVERAGES CERTIFICATE NUMBER: 19310279 REVISION NUMBER:see Remarks
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. _
OD' SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS
RANCE
Y 12013-MSHRRRG-018 1/1/2013 1/1/2014 ! EACH OCCURRENCE I5 1,000,000
r7
DAMAGE TO RENTED
ENERALLIABILITY IPREMI$ES Eaoccurance E
DE❑ OCCUR - 1 MEDEXP(Anyone Person) S
i PERSONAL& ADV INJURY $
ECT
GENERAL AGGREGATE $ 11000,000
MIT APPLIES PER: PRODUCTS-CDMPIOP AGG S
RO- LOC 5
AUTOMOBILE LIABILITY L COMBIENED p SINGLE LIMIT
ANY AUTO BODILY NJORYn (Per Parson) E
ALLOWNEO SCHEDULED BODILY INJURY(PeraccidenD Is
AUTOS AUTOS OP TV AMAGE
-OWNED (Peraccitlenl)
AUTOS NON
8
HIRED 1;; OS E
000
A UMBRELLA 2013-MSHRRRG-XS 1/1/2013 1/1/2014 1 EACHOCOURRENCE 5 10,000,000
X EXCESS LIA-MADE I AGGREGATE $ 10 000 000
DED X R5,00 E
WORXERSCOMPENSATION _:SORY.
AN DEMPLOYERS'UABIUTY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA I EL EACH ACCIDENT Is
OLk~~FFICER/MEMBER EXCLUDED? ❑
)f an atouibe IFI) E.L. DISEASE EA EMPLOYEE S
DESCRIPTIONOF OPERATIONS Xel. I E. I. DISEASE POLICY LIM" $
A 2013-MSHRRRG-018 1/1/2013 1/1/2014
Hospital Professional 1$1,000,000 Per Occurrence
Liability $3,000,000 Aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach Acord 101, ACditonal Remarks Schedule, it more apace is m,iod)
THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED: 1/10/2013 WITH ID: 19254964
Certificate is offered as Evidence of Insurance coverage for the 280 Maple Street and 560 Catalina
Drive properties in Ashland, OR. For their interest in these locations, City of Ashland, its
officers, employees and agents are included as Additional Insureds to the extent of the General
Liability limits noted.
CERTIFICATE HOLDER CANCELLATION
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
City of Ashland
20 East Main Street
Ashland, OR 97520
Coll:3992499 Tpl:1586388 Cert:19310274 01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Named Insured: Ashland Community Healthcare Services
(dba Ashland Community Hospital)
Policy Number: 2013-MSHRRRG-018
Endorsement No. 001 Additional Insured
This Endorsement amends Part 11- Insured to include specified organization for coverage as an
Additional Insured to the extent of the General Liability Limits, with retro-active coverage to
September I, 2010:
• City of Ashland, its elected and appointed officials, officers, agents, employees &
volunteers, 20 East Main Street, Ashland, OR 97520
Fdesignated her terms and condition of the Policy remain unchanged.
ndorsement which forms a part of and is for attachment to the Policy issued by the
Insurers, takes effect of the effective date of said Policy at the hour stated in
olicy and expires concurrently with said Policy unless another effective date is
below.
Authorized Representative:
Effective Date: 01/01/2013
Additional. Insured 27