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HomeMy WebLinkAboutCOI - Stanford Health Care - Expires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on Insurance ManagersP.O. Box HM 2450Hamilton HM JX Bermuda, 1-M0101-00-2021 9/1/2021 9/1/2022✓ Aon Insurance Managers ✓ SUMIT INSURANCE COMPANY LTD. (SUMIT) SUMIT Stanford Health CareLucile Packard Children's Hospital StanfordStanford Health Care-ValleyCarec/o 300 Pasteur Drive, Risk Mgmt MC5713Stanford CA 94305 Gilroy Fire Department7070 Chestnut StreetGilroy CA 95020 30 Re: Agreement between The City of Gilroy and Stanford Health Care for Professional Services (Emergency Medical Services) 8/2017 - Ongoing The City of Gilroy, its elected or appointed officals, boards, agencies, officers, agents, employees, and volunteers, and its elected or appointed officals, boards, agencies, officers, agents, employees, and volunteers, are included as additional insureds. SUMIT's general liability policy is a claims-made policy with an extended reporting period ("tail"). The extended reporting period is unlimited. Emergency Medicine 1,000,000 3,000,000 63521425 | 21-22 GL Only | Janet Sencenbaugh | 8/24/2021 1:25:21 PM (PDT) | Page 1 of 2 DocuSign Envelope ID: 5A2AEA31-26AE-4500-95DD-29D5474A4550 ',6&/$,0(5 H&HUWV2QOLQHFRP ,03257$17 ,IWKHFHUWLILFDWHKROGHULVDQ$'',7,21$/&29(5('3(5621WKHSROLF\ LHV PXVWEHHQGRUVHG$ VWDWHPHQWRQWKLVFHUWLILFDWHGRHVQRWFRQIHUULJKWVWRWKHFHUWLILFDWHKROGHULQOLHXRIVXFKHQGRUVHPHQW V  7KLV FHUWLILFDWH GRHV QRW FRQVWLWXWH D FRQWUDFW EHWZHHQDQGWKH&HUWLILFDWH+ROGHU QRUGRHVLWDIILUPDWLYHO\RUQHJDWLYHO\DPHQGH[WHQGRUDOWHUWKHFRYHUDJHDIIRUGHGE\WKHFRYHUDJH GRFXPHQWVOLVWHGWKHURQ SUMIT 63521425 | 21-22 GL Only | Janet Sencenbaugh | 8/24/2021 1:25:21 PM (PDT) | Page 2 of 2 DocuSign Envelope ID: 5A2AEA31-26AE-4500-95DD-29D5474A4550 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY SEA-003726836-01 SAN FRANCISCO, CA 94111 N Comp/Coll Ded 0 09/01/202257 UEN BB8105 X 1,000 09/02/2021 RE: Agreement between The City of Gilroy and Stanford Health Care for Professional Services. The City of Gilroy, its elected or appointed officials, boards, agencies, officers, agents, employees and volunteers are included as Additional Insured in accordance with the policy provisions of the Automobile Liability policy where required by written contract. Gilroy, CA 95020 Gilroy Fire Department TBD--AL-21-22 1,000,000 19682 FOUR EMBARCADERO CENTER, SUITE 1100 MARSH RISK & INSURANCE SERVICES CALIFORNIA LICENSE NO. 0437153 Lucile Packard Children’s Hospital Stanford Health Care & Stanford, CA 94305 300 Pasteur Drive MC5713 09/01/2021 707 Chestnut Street A Hartford Fire Insurance Co DocuSign Envelope ID: 5A2AEA31-26AE-4500-95DD-29D5474A4550 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 8/31/2021 Edgewood Partners Insurance Center One California Street,Suite 400 San Francisco CA 94111 Certificate 404-439-8000 404-439-8001 Certificate@epicbrokers.com SAFETY NATL CAS CORP 15105 STANHOS-01 Stanford Health Care c/o Risk Management 300 Pasteur Dr.MC 5555 Stanford CA 94305 354003028 A A XLDC4065557(AOS) PS 4065558 (WI) 9/1/2021 9/1/2021 9/1/2022 9/1/2022 1,000,000 1,000,000 1,000,000 RE:Agreement between The City of Gilroy and SHC for professional services Gilroy Fire Department 7070 Chestnut Street Gilroy CA 95020 DocuSign Envelope ID: 5A2AEA31-26AE-4500-95DD-29D5474A4550 SUMIT 2021-2022 Primary Captive Policy 1 SUMIT Insurance Company, Ltd c/o Aon Insurance Managers Ltd Aon House, 30 Woodbourne Ave. P.O. Box HM 2450 Hamilton, Bermuda HM JX Endorsement No. 5 Additional Insured Endorsement Policy #: 1-M0101-00-2021 First Named Insured: Stanford Health Care formerly known as Stanford Hospital and Clinics; Lucile Packard Children’s Hospital formerly known as Lucile Salter Packard Children’s Hospital dba Stanford Children’s Health; The Board of Trustees of the Leland Stanford Junior University for its School of Medicine (hereinafter called “Stanford School of Medicine”), fka Stanford School of Medicine and Blood Bank; Stanford Blood Center, LLC fka Stanford Blood Bank, LLC, fka Stanford School of Medicine and Blood Bank; The Risk Authority (“TRA”), fka Stanford University Medical Network Risk Authority (“SRA”), formerly Stanford Hospital & Clinics Risk Consulting (“SRC”); Stanford PET-CT, LLC; SUMIT Holding International, LLC; University Healthcare Alliance; CareCounsel, LLC; Stanford Health Care Advantage (“SHCA”) fka University Health Care Advantage (“UHCA”); Valley Care Health System d/b/a Stanford Health Care – Valley Care fka The Hospital Committee for the Livermore- Pleasanton Areas dba Valley Care Health System (“VCHS”); Valley Care Medical Foundation, Inc.; Valley Care Charitable Foundation Effective: September 1, 2021 It is hereby understood and agreed that the definition Insured is amended to include as an additional insured the person(s) or organization(s) on file with the C ompany, but only with respect to liability for “bodily injury”,” property damage”,” personal and advertising injury” or “damages”, and “expenses” and “costs” caused, in whole or in part, by an occurrence or wrongful act of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned or rented by you. All other terms and conditions of this policy remain unchanged. Authorized Representative: ____________________________________ DocuSign Envelope ID: 5A2AEA31-26AE-4500-95DD-29D5474A4550