Yvonne Adekale Provider Relations Specialist, Wyoming, APS Healthcare 2 Provided training to staff and services provider...
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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