Loading...
HomeMy WebLinkAboutCOI - Stanford Health Care - Expires 2024-09-01CERTIFICATE OF LIABILITY COVERAGE Issue Date ADMINISTRATOR COVERED PARTY COVERAGE PROVIDER TYPE OF COVERAGE POLICY NUMBER EFFECTIVE GENERAL LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / RESTRICTIONS / SPECIAL PROVISIONS: CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, WILL ENDEAVOR TO MAI L ______ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THIS ENTITY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE THIS CERTIFICATE IS ISSUED AS A 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 COVERAGE DOUMENTS BELOW. OTHER COVERAGES $ $ EXPIRATION General Aggregate GENERAL LIABILITY [ ] Claims Made [ ] Occurrence THE POLICIES LISTED BELOW HAVE BEEN ISSUED TO THE ENTITY 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 COVERAGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS AND CONDITIONS OF SUCH COVERAGE POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CANCELLATION LIABILITY COVERAGES PROFESSIONAL LIABILITY $ COVERAGE LIMITS PROFESSIONAL LIABILITY [ ] Claims Made [ ] Occurrence Each Occurrence Aggregate $ [ ] [ ] Each Occurrence [ ] [ ] 8/29/2023 Aon Insurance Managers P.O. Box HM 2450 Hamilton HM JX Bermuda, 1-M0101-00-2023 9/1/2023 9/1/2024 1,000,0003 Aon Insurance Managers 3,000,000 3 SUMIT INSURANCE COMPANY LTD. (SUMIT) SUMIT Stanford Health Care Lucile Packard Children's Hospital Stanford Stanford Health Care Tri-Valley c/o 300 Pasteur Drive, Risk Mgmt MC5713 Stanford CA 94305 City of Gilroy 7351 Rosanna Street Gilroy 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 officials, boards, agencies, officers, agents, employees, and volunteers, and its elected or appointed officials, boards, agencies, officers, agents, employees, and volunteers, are included as additional insureds. A waiver of subrogation applies in favor of the City of Gilroy, coverage is primary and non-contributory. Emergency Medicine 76017173 | 23-24 GL Only | Jayde Negrete | 8/29/2023 8:48:23 AM (PST) | Page 1 of 2 DocuSign Envelope ID: F7070CC2-67D0-4E9A-AD81-CC5FCB36B7FD DISCLAIMER eCertsOnline.com IMPORTANT If the certificate holder is an ADDITIONAL COVERED PERSON, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). This certificate does not constitute a contract between and the Certificate Holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the coverage documents listed theron. SUMIT 76017173 | 23-24 GL Only | Jayde Negrete | 8/29/2023 8:48:23 AM (PST) | Page 2 of 2 DocuSign Envelope ID: F7070CC2-67D0-4E9A-AD81-CC5FCB36B7FD 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 8/29/2023 Edgewood Partners Insurance Center One California Street,Suite 400 San Francisco CA 94111 Certificate 404-781-1700 Certificate@epicbrokers.com License#:OB29370 Safety National Casualty Corporation 15105 STANHOS-01 Stanford Health Care (SHC)&Stanford Children's Health (LPCH);c/o Risk Management 300 Pasteur Dr.MC 5555 Stanford CA 94305 609891164 A A XLDC4065557 PS4065558 9/1/2023 9/1/2023 9/1/2024 9/1/2024 1,000,000 1,000,000 1,000,000 RE:Agreement between The City of Gilroy and SHC for professional services Waiver of subrogation applies to the extent required by written contract. City of Gilroy 7351 Rosanna Street Gilroy CA 95020 DocuSign Envelope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‹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ocuSign Envelope ID: F7070CC2-67D0-4E9A-AD81-CC5FCB36B7FD