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HomeMy WebLinkAboutSH21-044 - ELLENSBURG FAMILY MEDICINE PROOF OF INSURANCEACORO® CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE DAM 11/101 11/10/202211 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 endomement(s). PRODUCER NAME: CONTACT CM&F Group CM&F Group Inc. IPML, Ert: 1-800-221-4904 uc No: nDDS mLL53: info@cmfgroup.com 110 West 40th Street 10th Floor, Suite 1000/1001 New York, NY 10018 INSURE S AFFORDING COVERAGE NAIC0 INSURERA: MEDICAL PROTECTIVE COMPANY -MPC EACH OCCURRENCE $ 1,000,000 INSURED INSURERB: INSURER C, Ellensburg Family Medicine 2156 PAYNE RD ELLENSBURG, WA98926-7898 INSURER o PREMISES Ea occurrence S 1,000,000 INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER: 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. ILTR TYPE OF INSURANCE ADOL SUER POUCYNUMBER POLICY EFF MMIDOrfyyy) POLICY EXP IMM1DDIYYYY1 UNITS A X COMMERCIAL GENERAL LIABILITY U54661 11/29/2021 11/29/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1571 OCCUR PREMISES Ea occurrence S 1,000,000 MED EXP (Anyone Person) $ PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 6,000,000 X POLICY PRO- LOC ECT PRODUCTS-COMP/OPAGG $ 6,000,000 $ OTHER: AUTOMOBILEUABILITY COMBINED SINGLE UNIT $ Ee .WdImi BODILY INJURY (Por pemon) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (PerawlOeM) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELALIAR H OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS MADE DED RETENTION$ $ WORKERSCOMPENSATION ANDEMPLOYERS'LUIBIUTY YIN PER OTH- STATUTE ER EACH ACCIDENT $ ANYPROPRIETOWPARTNEWEXECUTIVEEL OFFICERIMEMBEREXCWDEDT F-1 NIA EL -DISEASE EA EMPLOYEE $ (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $ A Professional Liability X U54661 11/29/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace Is required) Occurrence Coverage Professional Liability Additional Insured: KiBitas County Nurse Practitioner Group 205 W 5th Ave Ellensburg, WA98926 CERTIFICATE HOLDER CANCELLATION 205 County 205 WHOULD 5th AveAVB Ellensburg, WA98926 ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT/HORREDREPRESENTATIVE © 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A� o® CERTIFICATE OF LIABILITY INSURANCE oAT11/101Dl21 11/1012021 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(les) 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 NAME: T CMBF Group CM&F Group Inc. AX ac° i o Ert: 1.800-221-4904 AIC No ADDRESS: info�cmfgroup.cem 110 West 40th Street 10th Floor, Suite 1000/1001 X NeWYOrk, NY 10018 INSURE S AFFORDINGCOVERAGE NAICN INSURERA: MEDICAL PROTECTIVE COMPANY- MPC 11/29/2022 INSURED INSURERS: INSURERC: Ellensburg Family Medicine 2156 PAYNE RD ELLENSBURG, WA98926-7898 INSURERD: INSURER E: INSURER F: DAMA ET RENT D cc PREMISES Ea ourrence COVERAGES CERTIFICATE NUMBER: 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 LTRnm TYPE OF INSURANCE ADDL SUER wyn POLJCYNUMBER MOMII,DDYEFF Map TY' LIMITS A X COMMERCIALGENERALLUIBIUW X U54661 11/29/2021 11/29/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE I OCCUR DAMA ET RENT D cc PREMISES Ea ourrence $ 1,000,000 MED EXP (Any one person) $ PERSONAL S ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 6,000,000 X PDODY PRO- LOC PRODUCTS-COMPIOPAGG$ 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 nodded) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ It WORKERS COMPENSATION ANDEMPLOYERS-LUUBLITY YIN PER OTH- STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVEE.L. EACH ACCIDENT $ MI OFFICEREMBERMI-JOEDP F-1 NIA E.L. DISEASE -EA EMPLOYEE $ (Mandatory In NH) if yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY UMIT $ A Professional Liability U54661 11129/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace is required) Occurrence Coverage General Liability Additional Insured: Killitas County Nurse Practitioner Group 230 Grant Rd Ste B27 Ellensburg, WA98926 Kittitas County 230 Grant Rd Ste B27 205 W 5th Ave Ellensburg,WA98926 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATIVE (119AR-201R ACORD CORPORATION_ All riohte ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A� O® CERTIFICATE OF LIABILITY INSURANCE DAT11110/2021 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(les) 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 CM&F Group Inc. p"° Ne EH: 1-800-221-0904 � No: E-MAIL ss: info�cmfgroup.com 110 West 40th Street 10th Floor, Suite 1000/1001 New York, NY 10018 INSURE S AFFORDINGCOVERAGE NAIC0 INSURERA: MEDICAL PROTECTIVE COMPANY -MPG 11/29/2022 INSURED INSURERS: INSURERC: Ellensburg Family Medicine INsuRERo: 2156 PAYNE RD ELLENSBURG, WA98926-7898 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 OF INSURANCE ADDILSUBIType J02 vivo POUCYNUMBER MMIDBYEFF NINVIDDU� LIMITS A J( COMMERCIALGENERALUABILITY U54661 11/29/2021 11/29/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE Fx] OCCUR PREMISES Eaaccunenre $ 1,000,000 MED EXP (Any one pwson) $ PERSONAL&ADV INJURY $ 1,000,000 GEN -L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 6,000,000 X POLICY 0 PRO-JECT 1-1LOC PRODUCTS-COMP/OPAGG $ 6,000,000 IS OTHER: AmOMOBILE LUU$IDTY COMBINED SINGLE UNIT $ Ea accident BODILY I NJURY(Per person) $ ANY AUTO OWNED BCHEOULED AUTOS ONLY AT BODILY INJURY (Peraccident) $ PROPERTY DAMAGE $ Per acdtlenl HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LUIS OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORNERSCOMPENSATION AND EMPLOYERWLMBILITY YIN PER OTH- STATUTE ER ANYPROPRIETOTPARTNEWEXECUTIVEE.L. EACH ACCIDENT $ OFFICERIMEMSEREXCLUDED9 F-1 NIA E.L. DISEASE EA EMPLOYEE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONSItelm E.L. DISEASE -POUCY LIMIT $ A Professional Liability U54661 11/29/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space is required) Occurrence Coverage Nurse Practitioner Group CERTIFICATE HOLDER CANCELLATION Vittltas 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. AUT�HORVEDDREPR�tEESSENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ellensburg Family Medicine 2156 PAYNE RD ELLENSBURG, WA 98926-7898 Re: Policy# U54661 Dear Ellensburg Family Medicine Thank you for choosing CM&F Group, Inc. for your healthcare professional liability insurance needs. CM&F has been in business since 1919 and has provided stable, secure and reliable insurance programs to healthcare practitioners since 1947. When you consider our 65+ years of experience in the malpractice arena, coupled with the financial superiority of our carrier partners -you can rest assured that your professional integrity is very well protected. ENCLOSED ARE YOUR POLICY DOCUMENTS: 1. Multi -Specialty Healthcare Professional - CERTIFICATE 2. Mandatory & Optional Endorsements 3. Acord Certificate of Liability (PROOF OF INSURANCE) Please review these documents for accuracy and keep them in a safe place. If you have any questions, please call us at 1-800-221-4904 or send us an e-mail to: info@cmfgroup.com. Aside from providing access to the highest quality coverages on the market, we are fully committed to delivering superior customer service, so please know that we welcome your call should you have any questions or need assistance at any time. Your healthcare professional liability policy offers broad coverage, including the following policy features and benefits which we call "The CM &F Advantage". > Professional Liability $1,000,000/$6,000,000 > Medical Payments $25,000/$100,000 > License Defense $25,000/$100,000 > HIPAA Defense $25,000 > Deposition Defense $10,000 > First Aid Coverage $15,000 > Loss Of Earnings $2,500 per day/$35,000 > Good Samaritan Coverage Included > Biomedical Defense $10,000 > Assault Upon You $25,000 If you would like to review your coverage, please visit the CM&F Client Access Portal (www.MYCMFACCOUNT.cmn : The secure CM&F Client Access Portal is updated in real time with payments and balances so that you can track your costs, coverage and renewal dates - at your convenience 24/7. But should you need personal assistance, the CM&F Customer Care Team is at your service Monday - Friday: Customer Service Claim Team at 1-800-221-4904 Email: info@cmfgroup.com We wish you continued success and thank you again for choosing CM&F! Sincerely, The CM&F Group, Inc. 99 Hudson Street 12th Floor, New York, NY 10013-2815 info@cmfgroun.com I www.cmfgrouo.com 1.800.221.4904 The Medical Protective Company ASTOCK INS URANCE COMPANY 5814 Read Roatl, Fort Wayne, Indiana 46835 Strength. Defense. S'luil crs. Since 1899. MULTI -SPECIALTY HEALTHCARE PROFESSIONAL - CERTIFICATE Policy 2021-11-29 TO: 2022-11-29 Certificate Number: U54661 Period: at 12:01 a.m. Standard Tyra at Ne address of Ne First Named Insured. Item 1(a) Named Insured: N/A Student Non -Insured acting in the capacity of an Administrative First Named Insured Ellensburg Family Medicine Professional Services Specialty: NP Group Classification: N/A Item 1(b) Additional Insureds: First Named Insured Address: 2156 PAYNE RD New Business I X Renewal Business ELLENSBURG, WA 98926-7898 POLICY TYPE* RETROACTIVE LIMITS OF LIABILITY Citc,nrn,nos standard Converi COVERAGES: DATE Claims Made Claims Made Per Claim Aggregate PROFESSIONAL LIABILITY $1,000,000 $6,000,000 A. Professional Liability (PL) & Included Included B. Good Samaritan Acts $25,000 $25,000 C. Assault Upon You $15,000 $15,000 D. First Aid $25,000 $100,000 E. Medical Payments X $10,000 $10,000 F. Deposition Fees - Administrative Hearing Expense $25,000 $100,000 - Sexual Misconduct Expense $25,000 $25,000 - Loss of Earnings $2,500 $35,000 - HIPAA Proceeding Expense $25,000 $25,000 - Biomedical Waste Hearing Expense $10,000 $10,000 WORKPLACE LIABILITY A. Healthcare Professional Premises Liability & B. Personal Injury Liability WaAplmvL.fii, nanotapplyir Me tiomm eldirylimm Agnemenliamd,amlo(yp,r voa,. EMPLOYMENT PRACTICES LIABILITY" CYBER LIABILITY BILLING PRACTICES & REGULATORY COMMERCIAL GENERAL LIABILITY - Each Occurrence Limit $1,000,000 - Damages to Premises Rented $1,000,000 to an Insured Business $1,000,000 - Personal & Advertising Injury X $6,000,000 - General Aggregate Limit - Product Completed Operations Aggregate $6,000,000 - Hired and Non -Owned Auto General Liability dam not apply If Me Wodplace Ualmity moving Agreement is mad. Wrr oryoor coy made FORMS & ENDORSEMENTS: Master Policy Number: MMPOC19190 IN W 7NEEs5 WHEREOF, The Medial Protective Cannery has ra. ped this policy W be signaJ by its President and Corporate secretary (and SEE POLICY FORMS & ENDORSEMENTS SCHEDULE countersigned by its duty Auf rzed Remassntates. where neceesary). President Premium: $4,932.00 For Service or questions, please call: Surcharges: $0.00 CM&F Group, Inc. 1-800-221-4904 1 ',LJY"Ck4. n0� Taxes: $0.00 TOTAL: $4.932.00 1 Secretary *THIS POLICY CONTAINS CLAIMS -MADE COVERAGE. countersignature l Aummmed Representative ** CLAIM EXPENSE IS PAID WITHIN THE LIMITS OF LIABILITY. NOTICE LIMITS MAY CHANGE BY COVERAGE PROVISION OR ENDORSEMENT. PLEASE READ YOUR POLICY AND ENDORSEMENTS CAREFULLY. DISCUSS WITH YOUR INSURANCE AGENT IF NEEDED. 18011 01114 The Medical Protective Company° A STOCK INSURANCE COMPANY 5814 Reed Road, Fort Wayne, Indiana 46835 Strength. Defense. Solutions. Since 1899. MULTI -SPECIALTY HEALTHCARE PROFESSIONAL MASTER POLICY CERTIFICATE OF INSURANCE SCHEDULE OFPOLICYFORMS & ENDORSEMENTS Forms and Endorsements of your Certificate are as follows: Form # Description Form Be. ITitle IMCL (Cover Letter 118011 IMPS Multi -Specialty Healthcare Professionals Policy Certificate 118507 IMPS Multi -Specialty Healthcare Professionals Form 6 Endorsement Schedule 118505 IMPS Multi -Specialty Healthcare Professionals Policy Schedule of Insureds 118511 [General Definitions 118519 IGeneral Conditions 118522 IGeneral Exclusions 1 118528 (Professional Liability Insuring Agreement - Occurrence 118560 Commercial General Liability Insuring Agreement - Occurrence 118617 ]Disclosure Notice of Terrorism Insurance Coverage 118620 (Cap on Losses From Certified Acts of Terrorism Endorsement 118565 (Additional Insured - Lessors of Premises & Leased Equipment 119120 IMPS Economic Sanctions Exclusion Endorsement 119121 (Economic Sanctions Exclusions Endorsement (GL) 119098 IMPS Blanket Separate Limit Endorsement - PL Only 119187 (Biomedical Waste Hearing Expense Endorsement - Occurrence 119218 (Reuse or Multidose Supply Procedure Exclusion Endorsement 119631 (Procedures Exclusion Endorsement 118752 (Washington Amendatory Endorsement I 18507 All other terms and conditions of the Policy remain unchanged. 08/13 The Medical Protective Company° A STOCK INSURANCE COMPANY 5814 Reed Road, Fort Wayne, Indiana 46835 Strength. Defense. Solutions. Since 1899. MULTI -SPECIAL TY HEALTHCARE PROFESSIONAL MASTER POLICY SCHEDULE OFINSUREDS ENDORSEMENT Item I (a) of the CERTIFICATE is as follows: ITEM 1(a) NAMED INSURED PROFESSIONAL SERVICES PREMIUM SPECIALTY AFFILIATED ITEM 1(a) NAMED SURCHARGE TYPE MODIFIED PREMIUM RETROACTIVE I) Individual COVERAGE SURCHARGE DATE* E) Entity ENDORSEMENT TAXES CLASS (If Applicable) S) Student NUMBER (If Applicable) Ellensburg Family Medicine Each employee, shareholder, partner, volunteers or independent contractor Healthcare Professional of Ellensburg Family Medicine but only while providing professional services on behalf or under the direction or control of Ellensburg Family Medicine excluding any physician, podiatrist, chiropractor, optometrist, nurse midwife, certified registered nurse anesthetist or dentist unless designated as an Insured under your Certfcate or by endorsement listed on your certificate. Item I (b) of the is as follows: E Not Applicable Included Not Applicable Included Kittitas County All 1(a) Named Insureds Listed Above Included Kittitas County All 1(a) Named Insureds Listed Above Included All other terms and conditions of the Policy remain unchanged. 18505 08/13 PREMIUM AFFILIATED ITEM 1(a) NAMED SURCHARGE ITEM 1(b) ADDITIONAL INSURED INSURED TAXES (If Applicable) Kittitas County All 1(a) Named Insureds Listed Above Included Kittitas County All 1(a) Named Insureds Listed Above Included All other terms and conditions of the Policy remain unchanged. 18505 08/13