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A� o CERTIFICATE OF LIABILITY INSURANCE DATE2/02/202D/Y11 12/02/® 1 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: CM&F Group PHCN o , 1-800-221-4904 F4A/c No: CM&F Group Inc. 110 West 40th Street 10th Floor, Suite 1000/1001 E-MAIL cmf info rou ADDRESS: @ g p'com New York, NY 10018 INSURERS AFFORDING COVERAGE NAIC # INSURER A : MEDICAL PROTECTIVE COMPANY- MPC EACH OCCURRENCE $ 1,000,000 INSURED INSURER B INSURERC: Ellensburg Family Medicine 2156 PAYNE RD ELLENSBURG, WA98926-7898 INSURER D : DAMAGETO1,000,000 PREMISESSEa occurrence $ INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NLIMRER! 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM DD/YYYY POLICY EXP MM DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X U54661 11/29/2021 11/29/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGETO1,000,000 PREMISESSEa occurrence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 6,000,000 X POLICY u PRO- � JECT LOC PRODUCTS - COMP/OPAGG $ 6,000,000 $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNEWEXECU I VE OFFICER/M EMBER EXCLUDED? NIA PER OTH- STATUTE I I ER E L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ A Professional Liability 11/29/2021 11/29/2022 Per Incident 1,000,000 1-7 Aggregate 6,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Occurrence Coverage Professional Liability Additional Insured: General Liability Additional Insured: Kittitas County Kittitas County Nurse Practitioner Group 230 Grant Rd Ste B27 230 Grant Rd Ste B27 Ellensburg, WA98926 Ellensburg, WA98926 CERTIFICATE HOLDER CANCELLATION Kittitas County 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 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD