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HomeMy WebLinkAboutCAG2021-147 - Insurance Certificate - Cedar River Clinics - Liability Coverage - 04/20/2021INSR ADDL SUBR LTR INSR WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: 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) COMMERCIAL GENERAL LIABILITY AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person)$ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS AUTOS ONLY HIRED PROPERTY DAMAGE $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 LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED 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 any 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE General Star Indemnity Company 4/19/2021 USI Insurance Services LLC 2021 Spring Road, Suite 100 Oak Brook, IL 60523 312 442-7200 LaJeune Fitzpatrick 312 442-7200 610 362-8900 Feminist Women's Health Center dba Cedar River Clinics 106 East E Street Yakima, WA 98901 37362 A X IJG420576F 04/20/2021 04/20/2022 1,000,000 50,000 5,000 1,000,000 3,000,000 1,000,000 A Professional Liab IJG420576F 04/20/2021 04/20/2022 1,000,000 Per Claim 3,000,000 Aggregate 10,000 Deductible Coverage afforded the additional insured: City of Kent on a Primary and Non-contributory basis as per written contract. City of Kent 220 Fourth Avenue South Kent, WA 98032 1 of 1 #S31817429/M31816391 FEMINWOMClient#: 733737 PPKZP 1 of 1 #S31817429/M31816391 This page has been left blank intentionally. GENERAL STAR INDEMNITY COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement # 10 , effective April 20, 2021 forms a part of Policy # IJG420576F issued to Feminist Women's Health Center dba Cedar River Clinics by General Star Indemnity Company. ADDITIONAL INSUREDS - PRIMARY AND NON-CONTRIBUTORY CLAUSE -SCHEDULED This endorsement modifies insurance provided under the following: MISCELLANEOUS HEALTHCARE FACILITIES GENERAL LIABILITY COVERAGE PART COVERAGES A AND B PROVIDE CLAIMS -MADE COVERAGE MISCELLANEOUS HEALTHCARE FACILITIES — GENERAL LIABILITY INSURANCE COVERAGE PART OCCURRENCEFORM SCHEDULE Additional Insured(s): • City of Renton • City of Kent 1. For any additional insured(s) added by endorsement to this policy and scheduled above, any other insurance available to such additional insured(s), where they are Named Insured(s), shall be specifically excess of this insurance and this insurance shall be primary to and shall not seek contribution or indemnity from such insurance. 2. This endorsement applies to an additional insured only if you have agreed, in a written contract or agreement, to provide primary insurance to such additional insured on a non-contributory basis. 3. If, however, the additional insured has other insurance available as an additional insured on any other insurance policy, this endorsement shall not apply to such other insurance and this insurance shall apply on an excess basis. ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. MHF 20 0005 06 15 Copyright, General Star Management Company, Stamford, CT 2015 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission.