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HomeMy WebLinkAboutInsurance Certificate: Ashland Community Hospital-Liability CERTIFICATE OF LIABILITY INSURANCE Page 1 of 1 09/26/soii 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 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). PRODUCER I CONTACT Willie Management (Vermont) Ltd. PHONE FA% 26 Century Blvd. XTr 877-945-7378 Am 888-467-2378 P. 0. Box 305191 E-MAIL Nashville, TN 37230-5191 ADDRFSS certificates @willis.com INSURER(S)AFFORDING COVERAGE NAIC0 INSURERA:Mountain States Healthcare (RRRG) R2532-001 INSURED INSURER B: Ashland Community Hospital - 280 Maple StreetIII NSURER C. Ashland, OR 97520 INSURER D'. ' '(INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:16640466 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. INSR TypE OFINSURANCE 00' SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS NqAf A GENERALLIABILHY Y 2011-MSHRRRG-018 X1/1/2011 1/1/2012 EACHOCCURRENCE E 11000,000 COMMERCIAL GENERAL LIABILITY DAMAGET RENTED PREMISES Ea occumnce S X CLAIMS-MADE❑OCCUR MED EXP(My one ) $ PERSONAL A ADV INJURY $ GENERALAGGREGATE $ 1 000 00 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/DPAGG E X POLICY PRO- LOC E IFCT AUTOMOBILE MBILITY COMBINED SINGLE LIMIT teaccideml $ ALLOWNE I BODILY IWUR(Par person) S AU OS SCHEDULED AUTOS AUTOS BODILY INJURV(PerawNenQ S HIREDAUTOS NON OWNED AUTOS I Per ecc4enl)AMA E S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE I AGGREGATE E DED I RETENTIONS E WORKERS COMPENSATION AND EMPLOYERS'LIABILITY BY I IYAT FIR ANY PROPRIETORIPARTNER/EXECUTIVE Y/❑N N/A E.L.EACH ACCIDENT S OFIRCERMEMSER EXCLUDED? /Mandatory In NH) ( E.L.DI SEASE-EA EMPLOYEE § AOyS RIPTIDNOFO DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT § 'A 2011-MSHRRRO-018 1/1/2011 1/1/2012 Hospital Professional $1,000,000 Per Occurrence Liability $3,000,000 Aggregate Hospital DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach Acord 101,Addltonal Remarks Schedule.If mom space Is required) THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED: 9/19/2011 WITH ID: 16540925 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:3497539 Tp1:1326176 Cert:16640466 @1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE °AT912MI2011YY Lam 09/27/E011 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 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). PRODUCER AOn Risk Services Central, Illinois Division CONTACT 200 East Randolph Street - PHONE FAX INC NQ.EXL'11th Floor EMAIL INC.No: Chicago, IL 60601 ADDRESs: INSURERS AFFORDING COVERAGE NAIC a INSURERA:Mountain States Healthcare RRRG INSURED Ashland Community Hospital INSURER B: 280 Maple Street INSURER C Ashland,OR 97520 INSURER D: INSURER E: INSURER F, COVERAGES CERTIFICATE NUMBER: 292564 REVISION NUMBER: 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. LIMITS SHOWN ARE AS REQUESTED ILTR TYPE OF INSURANCE . 0 R POLICY NUMBER MM�DDIVYYY MM/OD/YYYY LIMITS WVD GENERAL LIABILITY EACH OCCURRENCE f COMMERCIAL GENERAL LIABILITY A PREMISES Ea occurrence f CLAIMS-MADE F-I OCCUR MED EXP(My one person) f PERSONAL 8 ADV INJURY S GENERAL AGGREGATE f GENL AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG f POLICY PRO LOC IFCT [7 f AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ecadenl ANY AUTO BODILY INJURY(Per person) f ALL OWNED F7 SCHEDULED AUTOS AUTOS I BODILY INJURY(Per accideml f NOWO HIRED AUTOS AUTOS MEO PROPERTYDAMAGE AUTOS Per accident $ E A UMBRELLALIAB OCCUR 2011-MSHRRRG-XS 1 1/1/2011 1/1/2012 EACH OCCURRENCE s 9,000,000 X EXCESS DAB x CIAiMSTMADE AGGREGATE f 9,000,000 DIED I I RETENTIONS f WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERSLIABIDTY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-1 NIA E.L.EACH ACCIDENT S (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE f If s,deaaibe under DESCRIPTION OF OPERATIONS halo E.L.DISEASE-POLICY LIMIT f DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is required) City of Ashland, its officers, employees and agents are named as additional insureds (excess of primary General and Professional Liability) with respect to the 280 Maple Street and 560 Catalina Drive properties in Ashland, OR. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 East Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland, OR 97520 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Named Insured: Ashland Community Hospital Policy Number: 201 1-MSHRRRG-018 Endorsement No. 003 Additional Insured This Endorsement supercedes the previously issued Endorsement No. 002 as follows: This Endorsement amends Part II— 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 All other terms and condition of the Policy remain unchanged. This endorsement which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect of the effective date of said Policy at the hour stated in said Policy and expires concurrently with said Policy unless another effective date is shown below. Authorized Representative: Effective Date: 10/12/2011 Additional. Insured 27