APS Healthcare - WV DHHR

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

07/11/2011

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). CONTACT 1-818-539-2300 PRODUCER Robin Johnston NAME: Arthur J. Gallagher & Co. FAX PHONE 818-539-1354 (A/C, No): 818-539-1654 (A/C, No, Ext): Insurance Brokers of California, Inc. License #0726293 E-MAIL 505 North Brand Boulevard, Suite 600 [email protected] ADDRESS: INSURER(S) AFFORDING COVERAGE

Glendale, CA 91203-3944

NAIC #

INSURED

INSURER B :

Great Northern Ins Co FEDERAL INS CO

Innovative Resource Group, LLC dba APS Healthcare Midwest 44 South Broadway, 12th Floor

INSURER C :

WAUSAU UNDERWRITERS INS CO

26042

INSURER D :

EMPLOYERS FIRE INS CO

20648

INSURER A :

20303 20281

INSURER E :

White Plains, NY 10601

INSURER F :

CERTIFICATE NUMBER: 22245558

COVERAGES

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. INSR LTR

A

TYPE OF INSURANCE

ADDL SUBR INSR WVD

X

POLICY NUMBER

35809570

GENERAL LIABILITY

06/30/11 06/30/12

COMMERCIAL GENERAL LIABILITY CLAIMS-MADE

X

OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER: PROPOLICY LOC JECT

B

POLICY EFF POLICY EXP (MM/DD/YYYY) (MM/DD/YYYY)

X

HIRED AUTOS

X

UMBRELLA LIAB

X

$ $

1,000,000 1,000,000

MED EXP (Any one person)

$

PERSONAL & ADV INJURY

$

10,000 1,000,000

GENERAL AGGREGATE

$

2,000,000

PRODUCTS - COMP/OP AGG

$

Included

$

73551981

AUTOMOBILE LIABILITY

ANY AUTO ALL OWNED AUTOS

LIMITS

EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence)

06/30/11 06/30/12

SCHEDULED AUTOS NON-OWNED AUTOS

COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person)

$ $

1,000,000

BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident)

$ $

B

X

EXCESS LIAB

C

D

79842253

OCCUR

06/30/11 06/30/12

CLAIMS-MADE

DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

Managed Care E&O

EACH OCCURRENCE

$

AGGREGATE

$

15,000,000 15,000,000

$

WCJ-Z91-454866-011

06/30/11 06/30/12 X

WC STATUTORY LIMITS

OTHER

E.L. EACH ACCIDENT

$

1,000,000

1,000,000 1,000,000 10,000,000

E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT

MCP-5024-11

06/30/11 06/30/12 Per Claim

Claims-Made -

Policy Aggregate

$

10,000,000

Subject to Policy Retro Dates DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

Subject to all policy terms, conditions, limitations and exclusions. West Virginia Department of Health and Human Resources, Bureau of Medical Services Department of Administration Purchasing Division is named as additional insured as required by written contract for general liability arising out of the operations of the Named Insured.

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.

State of WV - DHHR

2019 Washington St. E.

AUTHORIZED REPRESENTATIVE

Charleston, WV 25311 USA

ACORD 25 (2010/05) robijoh 22245558

© 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

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