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HomeMy WebLinkAboutPreempt Physical Therapy, LLC contract - insuranceDocuSign Envelope ID: EB273270-FCC2-4438-8CD0-BE8DF75CA7E1 DocuSign Envelope ID: EB273270-FCC2-4438-8CD0-BE8DF75CA7E1 DocuSign Envelope ID: EB273270-FCC2-4438-8CD0-BE8DF75CA7E1 DocuSign Envelope ID: EB273270-FCC2-4438-8CD0-BE8DF75CA7E1 DocuSign Envelope ID: EB273270-FCC2-4438-8CD0-BE8DF75CA7E1 2/20/2023 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICYPROVISIONS. INSURER(S)AFFORDINGCOVERAGE INSURERF: INSURERE : INSURERD : INSURERC : INSURERB : INSURERA : 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 THISCERTIFICATEMAYBEISSUEDORMAYPERTAIN,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. $ $ $ $PROPERTYDAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLELIMIT AUTOSONLY AUTOSAUTOSONLYNON-OWNED SCHEDULEDOWNED ANYAUTO AUTOMOBILELIABILITY Y /N WORKERSCOMPENSATION AND EMPLOYERS'LIABILITY OFFICER/MEMBEREXCLUDED?(MandatoryinNH) DESCRIPTION OF OPERATIONS belowIfyes,describe under ANYPROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L.DISEASE -POLICY LIMIT E.L.DISEASE -EA EMPLOYEE E.L.EACHACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICYEFFPOLICYNUMBERTYPEOFINSURANCELTRINSR DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101,AdditionalRemarks Schedule,maybe attached if more space isrequired) EXCESS LIAB UMBRELLALIAB $EACHOCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS-COMP/OP AGG $GENERALAGGREGATE $PERSONAL&ADV INJURY $MED EXP (Any oneperson) $EACHOCCURRENCE DAMAGETORENTED $PREMISES (Ea occurrence) COMMERCIALGENERAL LIABILITY CLAIMS-MADE OCCUR GEN'LAGGREGATE LIMIT APPLIESPER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) CANCELLATION AUTHORIZEDREPRESENTATIVE ACORD 25 (2016/03) ©1988-2016 ACORD CORPORATION.All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 07/14/2022 CM&F Group Inc. 110 West 40th Street 10th Floor, Suite 1000/1001 New York, NY 10018 Sara Ziegele 1545 Arboretum Drive Unit 222 Oshkosh, WI54901 CM&F Group 1-800-221-4904 info@cmfgroup.com MEDICAL PROTECTIVE COMPANY- MPC Sara Ziegele 1545 Arboretum Drive Unit 222 Oshkosh,WI54901 A Professional Liability U33891 08/01/2022 08/01/2023 Per Incident Aggregate 1,000,000 6,000,000 Occurrence Coverage Physical Therapist A X X X U33891 08/01/2022 08/01/2023 1,000,000 100,000 1,000,000 3,000,000 3,000,000