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HomeMy WebLinkAboutACH Insurance Certificates AC'ORIP" OP ID:4M �•.... EVIDENCE OF PROPERTY INSURANCE 0 os12or2o1 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE OF PROPERTY INSURANCE DOES NOT AMEND, EXTEND OF;ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AGENCY PHONE 541-779-1321 COMPANY A/C No E:t Western States Ins.-Me or Affiliated FM Ins Co 38 N.Central Ave Suite 100 Medford,OR 97501 Scott Sherbourne F,q/� .,541-779-9187 ADDRIESS: CODE: SUB CODE: AGENCY ASHLA-H CUSTOMER ID*: INSURED Ashland Community Hospital LOANNUMBER POLICY'NUMBER 280 Maple Street TT620 Ashland,OR 97520 EFFECTIVE DATE EXPIRATION DATE CONTINUED UNTIL 09/01/10 09/01111 TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATIONMLSCRIPTION 278-280 Maple Street Hospital Ashland,OR 97520 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 EVIDENCE OF PROPERTY INSURANCE 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 REDLCED BY PAID CLAIMS. COVERAGE INFORMATION COVERAGE/PERILS/FORMS AMOUNT OF INSURANCE DEDUCTIBLE Premise 1 Building 1 Building 50,000,000 10,0 Premise 4 Building 1 Building 2,250,000 10,0 REMARKS(including Special Conditions CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ADDITIONAL INTEREST NAME AND ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE X Lessor of Premises LOAN# City of Ashland Risk Management Division AUTHORIZED REPRESENTATIVE 20E Main St Ashland,OR 97520 ACORD 27(2006107) ©ACORD CORPORATION 1993-2006. All rights reserved. The ACORD name and logo are registered marks of ACORD EVIDENCE OF PROPERTY INSURANCE PROPERTY SCHEDULE 09120/2010 PAGE 2 PROPERTY INFORMATION LOCATIONIDESC RI PTION 560 Catalina Ashland,OR 97520 IT,IM Clinic PROPERTY INFORMATION L OCATIONIDESC RI PTION PROPERTY INFORMATION L OCATIONIDESCRIPTION PROPERTY INFORMATION LOCATIONIDE CRIPTION PROPERTY INFORMATION LOCATIO NID ESCRIPTION PROPERTY INFORMATION L OCATIO NA)ESCRI PTION PROPERTY INFORMATION L OCATIO NIDESCRI PTION PROPERTY INFORMATION L OCATIO NID E SCRI PTION ATTACH TO EVIDENCE OF PROPERTY APPLICATION ACORD• _ --- _ _ - _ ___ DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04,23,20,0 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 111 S.W.COLUMBIA HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR FIFTH FLOOR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PORTLAND,OR 97201 '- 902310--GLPXS-09-11 INSURERS AFFORDING COVERAGE NAIC# I INSURED INSURER A.Health Future Ins Exchange,A RRG 12263 Ashland Community Hospital r 280 Maple Street 1 INSURER B Lexington Insurance Company 19437 Ashland,OR 97520 1 NI SURER C i I I INSURER D. INSURER E. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NS R ADD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LT INSR DATE(MM/DDIYYYY) DATE(MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE 1,000,000 A X _ 6103-2009-10 09/01/2009 09/01/2011 DAMAGE TO RENTED B X COMMERCIAL GENERAL LIABILITY 6793055 09/01/2009 09/01/2011 PREMISES Ea occurrence $ X CLAIMS MADE OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 3,000,000 GENERAL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AG POLICY PRO JECT F7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS a (Per person) HIRED AUTOS BODILY INJURY $ NON OMED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT$ ANY AUTO OTHER THAN _EA ACC $ AUTO ONLY-. $ AGG B EXCESS I UMBRELLA LIABILITY 6793055 09/01/2009 09/01/2011 1 EACH OCCURRENCE $ 14,500,000 OCCUR E-1 CLAIMS MADE AGGREGATE $ 24,500,000 $ DEDUCTIBLE $ RETENTION $ 0. WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? L DISEASE_-EA EMPLOYEE$ (Mandatory in NH)If es,describe under SPECIAL PROVISIONS below .L.DISEASE-POLICY LIMIT $ OTHER A Professional Liability 6103-2009-10 09/01/2009 09/01/2011 Each Occurrence Limit $1,000,000 B 6793055 09/01/2009 09/01/2011 Aggregate Limiit $3,000,000 DESCRIPTION OF OPERATION S/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS The City of Ashland,it officers,employees and agents are added as an Additional Insured for General Liability regarding leased locations: 280 Maple Street and 560 Catalina Drive,Ashland,OR. This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group. Therefore,these funds Will not pay your claims or protect your assets if your risk retention group,the Insurer,becomes insolvent and is unable to make payments as promised. CERTIFICATE HOLDER SEA-001585175-02 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Ashland EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 East Main Street 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Ashland,OR 97520 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON pp ggEE THE INSURER, ITS AGENTS OR REPRESENTATIVES. or Mar8hEU5A InCSENTATnrE 0.— Lorie Larsen-Denning ACORD 25(2009/01) ©1998-2009 ACORD CORPORATION.All Rights Reserved The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. Acord 26(2009101)