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HomeMy WebLinkAboutTed S. Farr - Insurance CertificatePROGRESSIVE PO BOX 94739 CLEVELAND, OH 44101 668601 11752 1 AT 0.399 PPACS01W.068011752 CITY OF GILROY 7351 ROSANNA GILROY. CA 95020 II'll'Illiili'tii•'lily.i.l. Ills' I.III.I'iil'i'I.li.l..iili.l... Additional Insured Notice Named insured: TED S FARR TED S FARR CONSULTING 5920 RHINESTONE CT SALEM, OR 97306 Important notice from Progressive AMFOREWYE COMMERCIAL Policy number: 02813692-0 Undemntten by: Artisan and Truckers Casualty Cc Insured: TED .S FARR September 6, 2DI6 Policy Period: Dec 21, 2015 -.Dec 21, 2016 Mailing Address Artisao.and Truckers Casualty Co PO Box 94739 Cleveland, OH 44101 1. 800 -695 -2886 For customer service, 24 hours a day, 7 days a week Effective 09/05/2016 you are no longer listed as an additional insured on this policy. Form 4948 (09,04) PROGRESSIVE PAI�L�REll /l/E® PO BOX 9473g CLEVELAND, OH 44101 Policy number: 02813692-0 Underwritten by: Artisan and Truckers Casualty Co 950 Insured: TED S FARR 7351 CITY RO NNA December 22, 2015 GILROYY A A 950 20 Policy Period: Dec 21, 2015 - Dec 21, 2016 , CA Mailing Address Artisan and Truckers Casualty Co PO Box 94739 Additional insured endorsement Cleveland, OH 44101 1- 800 - 895 -2886 For customer service, 24 hours a day, Name of Person or Organization 7 days a week CITY OF GILROY 7351ROSANNA GILROY, CA 95020 The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be:primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodilylnji:ry Not applicable Property Damage Not applicable Combined Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 02813692 -0 Issued to (Name of Insured): TED S FARR TED S FARR CONSULTING Effective date of endorsement: 12/21/2015 Policy expiration date: 12/21/2016 Form 1198 (01104) 21161T416Y/ A Guide To Your General Liability Policy The following is a guide to your General Liability policy. We have identified several key coverage items along with the limits and deductibles you have selected. To make it easier, we have also added a brief explanation of those items. We want you to feel confident about your new policy. If any of the information below is incorrect or if you have any questions, please contact one of our advisors at 888 - 202 -3007 (Mon -Fri, 8am -10pm EST) or send us an e-mail at contact @hiscox.com. Name: Business Name: Address: City: State: Zip code: Occupation: Telephone number: Email address: Ted Farr Ted S Farr Consulting 5920 Rhinestone Ct SE SALEM OR 97306 First aid and CPR training 503 - 319 -7884 tedfarr57@gmail.com Policy number: UDC - 1405770- CGL -14 Policy effective dates: From: December 11, 2014 This determines the time period during which your coverage applies. TO December 11, 2015 Form of business: This identifies the legal structure of your business and determines who is Individual /Sole Proprietor insured under your policy. Optional terrorism coverage: Total cost of policy: Included $ 400.00 © Hiscox Inc. 2010 Page 1 Your coverage and limits Each occurrence limit $ 1,000,000 The most we will pay for all damages due to bodily injury and property damage, and medical expenses that arise out of any one occurrence. Defense costs we incur, in the defense of a lawsuit filed against you, will not reduce this limit. General aggregate limit $ 2,000,000 The most we will pay for all damages and medical expenses for the entire policy. Defense costs we incur, in the defense of a lawsuit filed against you, will not reduce this limit. Damage to premises rented to you $ 100,000 any one premises The most we will pay for damages, for which you are liable, to any one premises that is rented to you. This may include office space, conference rooms or training facilities, but does not include your primary residence if you are a home -based business. Medical expenses $ 5,000 any one person The most we will pay for all medical expenses sustained by any one person. Personal and advertising injury limit $1,000,000 any one person The most we will pay for all personal and advertising injury or organization (e.g., libel, slander) sustained by any one person or organization. Deductible No deductible No deductible applies to your policy so you are not required to make any payments in the event of such claims. 14 day full refund Be confident that you have made the right choice. We give you 14 days to review your policy. If you are not satisfied and have not had any claims or losses, you can cancel your policy back to its start date and receive a full refund. Notice of claim If you have a claim, please call us at 888- 202 -3007. You may also e-mail us at reportaclaim @hiscox.com What does my General Liability Policy cover? For a summary showing examples of what you are and are not covered for, please read the Coverage Summary document. This guide does not modify the terms and conditions of your policy, which are contained in your policy documents, nor does it imply any claim is covered or not covered. We recommend that you read your policy documents to learn the details of your coverage. © Hiscox Inc. 2010 Page 2 ^ #11 H ISCOX Reinventing Small Business Insurance'" General Liability Insurance Health, Beauty and Wellbeing Professionals We want you to understand the Hiscox General Liability coverage. This summary explains the main areas of coverage and exclusions. If you have any questions about your coverage, please contact one of our advisors at 888 - 202 -3007 (Mon -Fri, 8am -10pm EST) or via e -mail at contact @hiscox.com. Z This policy does cover Bodily injury or property damage To the extent you are legally liable, we cover damages or claims expenses if you injure a third -party or damage someone else's property (including damage due to a fire at a premise you rent, unless you work from home). However, such damage must not be as a result of your professional services. Bodily injury that occurs to a third - party as a result of your professional services may be covered by our Professional Liability policy. Medical payments We will make medical payments as a result of bodily injury that occurs in the course of your business operations, regardless of fault. Defense costs If you're sued, even if you're not at fault, we will appoint an attorney to defend you, even if the lawsuit is groundless. We will pay these defense costs on your behalf. Personal and advertising injury We cover claims of libel and slander that are not part of your professional services. We also protect you if your advertisement unintentionally uses a third - party's advertising idea or infringes upon another's copyright. Worldwide insurance coverage We cover damage that occurs in the United States, its territories and Canada. We also offer some coverage for instances outside these areas while you're away on short periods of travel. Employees, temporary staff or volunteers Hiscox will cover claims arising from actions of your employees, temporary staff, or volunteers if they were performed on behalf of your business. Supplemental payments Your Hiscox policy covers the following expenses, should they be incurred, without reducing your limit of liability: • all expenses we incur, including the defense of lawsuits • up to $250 a day for reasonable expenses (including loss of earnings) you incur as a result of assisting us in the defense of a claim or lawsuit • interest on damage awards. GI This policy does not cover Intent to injure We won't cover you for any act that occurs with the intent to injure. This includes personal and advertising injuries if you knew your actions were false or violated the rights of others. Outside the policy period We won't cover claims for bodily injury, property damage, or personal and advertising injury that do not occur during the policy period. Known claims and circumstances We won't cover your business for any claim or circumstance that could result in a claim you knew about prior to the start of your first Hiscox policy. Personally identifiable information We won't cover your failure to protect any personally identifiable information that is in your care. These types of risks may be covered on a limited basis as part of our Professional Liability Policy. Professional services We won't cover any professional services performed by you. These types of risks may be covered as part of our Professional Liability Policy. Vehicles and boats We won't cover any claims arising out of the ownership or use of an automobile or a watercraft. Workers' compensation We won't cover any obligation you may have under a worker's compensation claim or similar law. Your property We won't cover claims for damage to property you own or have in your care. Common claims examples Bodily injury During an appointment you leave your client unattended while you answer the phone. When you return you see that your client has tripped over a piece of business equipment and injured his hip and is unable to get up. We will cover the subsequent claim and related medical expenses up to your limits of liability. Property damage You spill coffee on a client's laptop causing damage. We will cover the subsequent claim up to your limits of li- ability. Personal injury One of your employees is gossiping with a long standing client. She talks about one of your new clients in a false and unflattering way. The client learns of this discussion and sues for slander. We will cover the subsequent claim, up to your limits of liability, and pay for an attorney to defend you if necessary. Coverage summaries, descriptions, and claims examples are provided for illustrative purposes only and are subject to the applicable policy limits, deductibles, exclusions, terms, and conditions. Not all insurance products and services are available in all states. Hiscox recommends you read the policy documents to learn the full details of coverage. Underwritten by Hiscox Insurance Company Inc., 104 South Michigan Avenue, Suite 600, Chicago, IL 60603, as administered by Hiscox Inc., a licensed insurance provider in all states and DC. 40 H I SCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) 104 South Michigan Avenue, Suite 600 Chicago Illinois 60603 Certificate of Commercial General Liability Insurance This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regardless of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Named Insured: Insurer Name: Policy Number: Type of Coverage: Policy Effective Date: Limits of Insurance Each Occurrence: Ted S Farr Consulting Hiscox Insurance Company Inc. UDC - 1405770- CGL -14 Occurrence December 11, 2014 Damage to Premises Rented to You: Medical Expense: Personal & Advertising Injury: General Aggregate: Products /Completed Operations Aggregate: General Aggregate Limit applies per: Description of Endorsements /Special Provisions Not applicable 44 - ( J�Q' Authorized Representative Policy Expiration Date: I December 11, 2015 $ 1,000,000 $ 100,000 Any one premises $ 5,000 Any one person $ 1,000,000 $ 2,000,000 Products - completed operations are subject to the General Aggregate Limit Policy October 27, 2014 Date CG DS 01 01 10 Includes copyrighted material of Insurance Services Office, Inc., with Page 1 its permission. © ISO Properties, Inc., 2000 AM HISCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) 104 South Michigan Avenue, Suite 600 Chicago Illinois 60603 Certificate of Commercial General Liability Insurance This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regardless of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Named Insured: Insurer Name: Policy Number: Type of Coverage: Policy Effective Date: Limits of Insurance Each Occurrence: Ted S Farr Consulting Hiscox Insurance Company Inc. UDC - 1405770- CGL -14 Occurrence December 11, 2014 Damage to Premises Rented to You: Medical Expense: Personal & Advertising Injury: General Aggregate: Products /Completed Operations Aggregate: Policy Expiration Date: I December 11, 2015 $ 1,000,000 $ 100,000 Any one premises $ 5,000 Any one person $ 1,000,000 $ 2,000,000 Products - completed operations are subject to the General Aggregate Limit General Aggregate Limit applies per: I Policy Description of Endorsements /Special Provisions Not applicable Additional Insured Status Certificate holder maintains Additional Insured Status if this boxed checked. This certificate does not grant any coverage or rights to the certificate holder. If this certificate indicates that the certificate holder is an additional insured, the policy(ies) must either be endorsed or contain spe -cific language providing the certificate holder with additional insured status. The certificate holder is an additional insured only to the extent indicated in such policy language or endorsement. Cancellation In the event of cancellation of any policy described above, the insurer will attempt to mail 10 days written notice to the certificate holder prior to the effective date of cancellation. However, failure to do so will not impose any duty or liability upon the insurer, its agents or representatives, nor will it delay cancellation. CG DS 01 01 10 Includes copyrighted material of Insurance Services Office, Inc., with Page 2 its permission. © ISO Properties, Inc., 2000 40 H I SCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) 104 South Michigan Avenue, Suite 600 Chicago Illinois 60603 The City of Milpitas; its officers, officials, employees, and volunteers Certificate Holder — (4j4V' Authorized Representative October 27, 2014 Date October 27, 2014 Date CG DS 01 01 10 Includes copyrighted material of Insurance Services Office, Inc., with Page 3 its permission. © ISO Properties, Inc., 2000 lr�,t' HISCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) 104 South Michigan Avenue, Suite 600 Chicago Illinois 60603 Certificate of Commercial General Liability Insurance This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regardless of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Named Insured: Insurer Name: Policy Number: Type of Coverage: Policy Effective Date: Limits of Insurance Each Occurrence: Ted S Farr Consulting Hiscox Insurance Company Inc. UDC - 1405770- CGL -14 Occurrence December 11, 2014 Damage to Premises Rented to You: Medical Expense: Personal &Advertising Injury: General Aggregate: Products /Completed Operations Aggregate: General Aggregate Limit applies per: Description of Endorsements /Special Provisions Not applicable Policy Expiration Date: I December 11, 2015 $ 1,000,000 $ 100,000 Any one premises $ 5,000 Any one person $ 1,000,000 $ 2,000,000 Products - completed operations are subject to the General Aggregate Limit Policy Additional Insured Status Certificate holder maintains Additional Insured Status if this boxed checked. This certificate does not grant any coverage or rights to the certificate holder. If this certificate indicates that the certificate holder is an additional insured, the policy(ies) must either be endorsed or contain spe -cific language providing the certificate holder with additional insured status. The certificate holder is an additional insured only to the extent indicated in such policy language or endorsement. Cancellation In the event of cancellation of any policy described above, the insurer will attempt to mail 10 days written notice to the certificate holder prior to the effective date of cancellation. However, failure to do so will not impose any duty or liability upon the insurer, its agents or representatives, nor will it delay cancellation. CG DS 01 01 10 Includes copyrighted material of Insurance Services Office, Inc., with Page 4 its permission. © ISO Properties, Inc., 2000 VAM HISCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) 104 South Michigan Avenue, Suite 600 Chicago Illinois 60603 The City of Gilroy, it's officers, officials and employees. October 27, 2014 Certificate Holder jgu Q - ( Authorized Representative Date October 27, 2014 Date CG DS 01 01 10 Includes copyrighted material of Insurance Services Office, Inc., with Page 5 its permission. C ISO Properties, Inc., 2000 Print Date: 6/18/2014 HEALTHCARE PROVIDERS SERVICE MHPSO CNA ORGANIZATION PURCHASING GROUP Certificate of Inoranee HcalrhmmPr- idenSmice0rpnhafiw OCCURENCE POLICY FORM Producer Branch Prefix 018098 970 HPG Named Insured and Address: Ted S Farr 5920 Rhinestone Ct Se Salem, OR 97306 -3545 Medical Specialty: Paramedic Policy Number Policy Period 0312598226 from 07/21/14 to 07/21/15 at 12:01 AM Standard Time Program Administered by: Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 19040 -1218 1- 800 -982 -9491 www.hpso.com Code: Insurance is provided by: 80723 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate. Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $ 100,000 aggregate First Aid $10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire & Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $ 277.00 ,Base Premium $277.00 Premium reflects Self Employed , Full Time Policy Forms & Endorsements (Please see attached list for a general description of many common policy forms and endorsements.) G- 121500 -D G- 121503 -C GSL15564 GSL15565 GSL3908 G- 123828 -B G- 121501 -C G- 145184 -A GSL17101 GSL13424 (02) GSL -5587 G- 147292 -A GSL15563 G- 123846 -C36 GSL3886 Medical Speciality is amended to include Consulting Services (GSL -5587) Keep this document in a safe place. ft p , f and proof of payment are your proof coverage. There is no coverage in force un less the premium is paid in full. In order to activate your coverage, please remit Chairman Of the Board Secretary premium in full by the effective date of this Certificate of Insurance. Master Policy# 188711433 G- 141241 -B (03/2010) Coverage Change Date: Endorsement Change Date: POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. Think Green —expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G- 121500 -D Common Policy Conditions G- 121503 -C Workplace Liability Form G- 121501 -C Occurrence Policy Form G- 145184 -A Policyholder Notice - OFAC Compliance Notice G- 147292 -A Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals G- 123846 -C36 Oregon Cancellation and Non - Renewal GSL3886 Coverage & Cap on Losses from Certified Acts Terrorism GSL3908 Notice - Offer of Terrorism Coverage & Disclosure of Premium OPTIONAL ENDORSEMENTS FORM # DESCRIPTION G- 123828 -B (02) Certificate Holder GSL =5587 Consulting Services Liability Endorsement PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and /or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association - 2012 Regular Assessment. Form* G - 141241 -B (03/2010) Named Insured:Ted S Farr Master Policy* 188711433 Policy* 0312598226 co zn° CERTIFICATE OF LIABILITY INSURANCE D IDOTYYYY) D 6106/os /cola PROOUCER PAUL RICHTER, AGENT THIS 6ERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6093 COMt4CRCIAL ST SE SUITE 160 SALES, OR 97302 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PIRATION DATE EMMIDOY LOIRE GILROY, CA 45020 INSURERS AFFORDING COVERAGE NA1C 0 INSURERA: State Farm Fire and Ca63alt Company 25143 25163 INSURED INSURERB:State Farm Mutual Auto Insaracae Copany 25178 25178 FAIR' TED 5920 RHINESTONE CT BE Snmm OR 97306 -3545 INSURER C: INSURER D: 5 N6URER E: THE POLICIES OF INSURANCE LISTEO 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 CERTWICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREJN IS SUBJECT TO ALL TK- TERNS, EXCLUSIONS AND CONDITIONS OF SUCH PO ICIE . AGGREGATE LIMITS SWHOVWMMN MAYHAVE BEEN REDUCED BY PAID CLAIMS. 181 IT-1 ADM IN$ TYPE OF INSURANCE POLICY NUMBER P DATE ME= PIRATION DATE EMMIDOY LOIRE GILROY, CA 45020 REPRESENTATIVES. 7 GENERALLIAMLITY COWERCIAL GENERAL CA81LITY CLAIMS MADE 11 OCCUR - EACH OCCURRENCE 6 PREMISE Ea ooe,nqnml S MEI)EXP(Anyy*9Iwwr4 5 PERSONAL b ADV INJURY GENERALAOCIREGAR 01714L/KiC>sLECATE(MSTAPRESPER PRO• P Y FLOC CT PRODUCTS -COMPiOP AGO B X .— AUTOMOBILE LIABILITY ANY AUTO X ALLOWNEQAUTOS SOHEOULEOAUTOE HIRED AUTOS X_ NON•OWNEDAIROB 205 6498- B04 -37J 053 2351- D29 -37C 068.6.190 -D15 -37C 02/C4/12 04/79112 09./15/12. 06/04/12 10/29/12 10/15.112 04MBINED SINGLE LIMIT (Es Awid.1) $ "Ono Y INJURY IPe Pm ) 6 250,000 000I6Y INJURY (PIEaeddemJ f 500,000 PROPERTYDAMAOE (Pa eCddeFAI S 100,000 . OARAQELIABILITY - ANYAUTO AUTO ONLY -£A ACCIDENT S OTHERTHAN FAACC AUTO ONLY: AGO 6 S EKCE6 "RELLA LIABILITY OCCUR aCLA1118MADE RDEDUCTIBLE R12TE)ITION S EACH O URRENCE S AGGREGATE S 6 6 WORKERS EMPLOYERS' COMPENSATION AND ANY PROPRIETORIPARTNERIEXECUTNE OFFICEWMEMBER EXCLUDED? IIrysc, dascnbe under S- ALPRONSI3148b.1- - 1VC BTATU• m• ORY L l , E.L EACH ACCIDENT `. 6 EL DISEASE. EA EMPLOYEE 6 E DISEASE - POLICY LIMIT 6 A OTHER PERSONAL LIABILITY 37 -F7- 0896 -9 F -06 /01/12 07/01/13 $1,000,000 - OESCRIPTION OF OPERATIONS J LOCATIONS 1 VEHICLES I EXCLU 11ONS ADDED BY ENDORSEMENT J SPECIAL PROVISIONS !AIJCEI_LATION ADDITIONAL INSURED! SHOULD ANY OF THE ABOVE DE4=090 POLICIES 0E CANCELLED OCFURE THE EXPIRATION CITY OF GILROY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL M DAYS WRITTEN ITS OFFICERS & EMPLOYEES NOTICE TOYHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 80 BIALL 7070 CHESTNUT ST IMPOSE NO OOL1flA7N1 LIABILITY OF ANY WHO UPON THE INSURER, ITS AOENTE OR GILROY, CA 45020 REPRESENTATIVES. 7 AUTHOR¢EO R9PRE9 E ICrtimp or Dig marKs uy inee TeSpeCOVe oWnemp VAGURV \,VRrVI[AIIV I'11S66, euQ1 All Tights reserved IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this cerlificate does not confer rights to the certificate holder In Neu of such endorsement(s). 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 or such endorsement(s). DISCLAIMER The Certificate of insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 2512001/08) �►co CERTIFICATE OF LIABILITY INSURANCE D04 /29I /2013) 04/29/2013 PRODUCER PAUL RICHTER, AGENT 4093 COMMERCIAL ST SE SUITE 160 SALEM, OR 97302 THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BEL OW. TYPE OF INSURANCE I a_ INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: State Farm Fire and Casualty Company 25143 25143 INSURER e: State Farm mutual Auto Insurance Company 25178 25178 FARR, TED INSURER C: EACH OCCURRENCE 5920 RHINESTONE CT SE SALEM OR 97306 -3545 INSURER D: INSURER E. S 1 %ICOA(_CC 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LT, ADD 'L INSRO TYPE OF INSURANCE POLICY NUMBER POMCY EFFECTIVE DATE(MMIDDIYY ) POLICY EXPIRATION DATE MMIDDM) LIMITS REPRESENTATIVES. AUTHORIZED REP ESE4 TATNE^ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S OAMAGET T D PREMISES (Ea occurrence S. MED EXP An one erson S CLAIMS MADE OCCUR PERSONAL &ADV INJURY _ $ _ GENERAL AGGREGATE $ GENLAGGREGATEUNITAPPLIES PER PRODUCTS - COMPIOP AGG S PRO - POLICY JECT LOD E X AUTOMOBILE LIABILITY 205 6498- E04-375 053 2351- D29 -37C 02/04/13 04/29/13 08/04/13 10/29/13 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 068 6190 -D15 -37C 04/15/13 10/15/13 X BODILY INJURY (Per person) $ 250,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) S 500,000 HIRED AUTOS NON -OWNED AUTOS X PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY - EAACCIDENT $ OTHER THAN EA ACC AUTO ONLY AGG S ANY AUTO S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE S OCCUR F-ICI-AIMS MADE 5 $ DEDUCTIBLE IS RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE WC STATU- OTH- TORY LIMITS ER EL EACRACCIDENT $ E.L DISEASE- EA EMPLOYEE S OFFICERIMEMBER EXCLUDED? E.L DISEASE - POLICY LIMIT $ If yes, describe under SPECIAL PROVISIONS below A " OTHER PERSONAL LIABILITY 37- E7- 089¢ -9 F 04/29/13 06/01/14 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS nvc, lo!`AT'C U111 DER CANCFLLAI ION ADDITIONAL INSURED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF GILROY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN ITS OFFICERS & EMPLOYEES NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $0 SHALL 7070 CHESTNUT ST IMPOSE NO OBLI ATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR GILROY, CA 95020 REPRESENTATIVES. AUTHORIZED REP ESE4 TATNE^ ACORD 25 (2001106) I ne registration notices Indicate dwneimeP m ulc nleioa vy U-11 I—P-1— -_- 132849 03 -13 -2007 All Fight$ Fe$erved HEALTHCARE PROVIDERS SERVICE CNAORGANIZATION PURCHASING GROUP Certificate of ln ural<rce OCCURENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 0312598226 from 07121/131 Print Date: 7/15/2013 MHPSO o 07/21/14 at 12:01 AM Standard Time Named Insured and Address: Ted S Farr 5920 Rhinestone Ct Se Salem, OR 97306 -3545 Medical Specialty: Paramedic Program Administered by: Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 19040 -1218 1 -800- 982 -9491 www.hpso.com Code: Insurance Is provided by: 80723 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $ 100,000 aggregate First Aid $ 10,000 per incident $10,000 aggregate Damage to Property of Others $10,000 per incident $10,000 aggregate Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire & Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $ 277.00 Base Premium $277.00 Premium reflects Self Employed , Full Time Policy Forms & E ndorsements(P lease see attached list for a general description of many common policy forms and endorsements.) G- 121500 -D G- 121503 -C G- 121501 -C G- 145184 -A G- 147292 -A GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 G- 123846 -C36 GSL3886 GSL3908 GSL -5587 Medical Speciality is amended to include Consulting Services (GSL -5587) Keep this document in a safe place, It p , f and proof of payment are your proof of coverage. There is no coverage in force U unless the premium is paid in full. In ordet to activate your coverage, please remit Chairman of the Board Secretary premium in full by the effective date of this Certificate of Insurance. Master Policy # 188711433 G- 141241 -6 (03/2010) Coverage Change Date: Endorsement Change Date: POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. Please refer to your Certificate of Insurance for the policy'forms & endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. Think Green — expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G- 121500 -D Common Policy Conditions G- 121503 -C Workplace Liability Form G- 121501 -C Occurrence Policy Form G- 145184 -A Policyholder Notice - OFAC Compliance Notice G- 147292 -A Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals G- 123846 -C36 Oregon Cancellation and Non - Renewal GSL3886 Coverage & Cap on Losses from Certified Acts Terrorism GSL3908 Notice - Offer of Terrorism Coverage & Disclosure of Premium OPTIONAL ENDORSEMENTS FORM # DESCRIPTION GSL -5587 Consulting Services Liability Endorsement PLEASE REFER TO YOURCERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and /or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association - 2012 Regular Assessment. Form #: G- 141241 -6 {03/2010} Named Insured:Ted S Farr Master Policy* 188711433 Policy#: 0312598226