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HomeMy WebLinkAboutCertificates of InsuranceACORD„ CERTIFICA r c OF LIABILITY INSUF ,NCE 10/01/200 PRODUCER Isaksen Insurance Inc 30233 Overseas Highway 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 POLICIES BELOW. Big Pine Key„ FL 33043 P: 305-872-0097 F: 305-872-1005 INSURERS AFFORDING COVERAGE INSURED INSURER A: HULL & COMPANY/Burlington Insurance Cc Rural Health Network of Monroe INSURERB: Hull & Company/Empire Fire & Marine Ins P. 0. Box 4966 INSURERC: Unisource / AIG Insurance Group RE:Poinciana Plz Bld 1623 4d Key West FL 33045- INSURERD: Burns & Wilcox/U.S. Liability Ins Cc INSURER E: ww�•rs ww_�c� 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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE INIM1DQrM POLICY EXPIRATION LIMITS A GENERAL LIABILITY ❑ COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE � OCCUR ❑ 164BOS0179 08/06/2002 08/06/2003 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Anyone fire) $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ ❑ GENERAL AGGREGATE $ 1,000,000 -E!!'L AGGP.EGR.TE LIk!!r wcPLIES PER- ❑ POLICY PRO ❑ LOC ❑ PRODUCTS - COMP/013 AGG $ _ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CL220922 08/06/2002 08/06/2003 COMBINED SINGLE LIMIT (Eaaceident) $ 1,000,000 BODILY INJURY (Per person) $ ❑ BODILY INJURY (Per accident) $ ❑ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ❑ ANY AUTO ❑ BY I a& AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS LIABILITY ❑ OCCUR �❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WAIVERIlA AYES / '+ �w/ / EACH OCCURRENCE $ AGGREGATE $ S _ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 723-89-42 05/15/2002 05/15/2003 WC STATU- OTH- E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. viSEASE - PO iCY LiioiiT I S 500,00C, D OTHER D & O 01013503B 03/09/2002 03/09/2003 Liability 1,000,000 DESCRIPTION OF OPERAMONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER IIAII ADDITIONAL INSURED: INSURER LETTER: L;ANLitLLAIIUN Monroe County BOCC 1100 Simonton Street Atten: Ann Mytniki Key West FL 33040- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OSLIGATIOJI OR LIABVTY OF �ANY KIND UPON THE INSURER ITS AGENTS OR RFPRESENTATIVES. A cS iT / 7� r^ (305) 295-3672 FAX ACORD 25-S (7/97) / , CG OACORD CORPORATION 1988 JAM-30-02 16:27 PROM:MONROF OUNTY PURCHASING ID:3052924515 PAGE 2/2 1996 MIM MONROE COUNTY, FLORIDA j Request For Waiver of Ilmsnrance Requirements ft is regltasted lilac the bmumm MquiremaM as specified is the Co+mrfs Schedule of ]nsiumnre Rephvmeams. be waived or modified on the foHow* coeoaaL CAUwactor. Rural Health Network of Monroe Count �! CaoUW for. Primary health care services Addreasof Post Office Box 4966; Key West, FL 33041-4966 Phones 305-293-7570 SeopeofWosiC primary health care services RmsaafbrWaiver, RHNMC believes the coverages are adequate based on the nature of our business Adeaua a nrP-a„tionary nro-Pdnre are in place. �� workers compensation coverage Foud"ver w171 apply Ur -- gee of convaawr ` Approved � Not Approved Risk N Dame County Admmtsb0or appd: Approvet Not Approved. Dame: Hoed of Cau ty commissioners appeal: Approvd: _ Not Approved: I Metfog Daft: - Adiaariaa� Insenaion "709.2 103 • _ 0R.CERTIFICATE . Y INSURANCE OATS (M /0 01/16/200 a PRODUCER 74IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Isakaen Insurance Inc ?JLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE :OLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 30233 Overseas Highway 0,TERTHE COVERAGE AFFORDED BY THE POLICIES BELOW. Big Pine Key„ FL 33043 P:305-872-0097 7:305-872-IOOS INSURERS AFFORDING COVERAGE INSURED _ I al.,'JRER A HULL & COMPANY/BURLTNGTON INSURANCE Rural Health Network of Monroe : ERB Hull & COMPANY/EMPIRE FIRE & MARINE P. O. Box 4966 --10 All RISKS LIMITED/EVANSTON ISNURAINCE RE:Poinciana Pla Bld 1623 4d :--RD: BURNS & WILCOX/UNITED STATES LIABILITY Rey West FL 33045- ^GR E VERAGES VO THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUCD TO THE INSUTtE : ?IAMEO ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT 'i, ( OT -IrR JOCU> =.: IT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES 3U©JECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUC;SO 3Y PAID CL,,,*, - INSR LTR TYPE OF INSURANCE __.FFECTIVE POLICY NUILIES:'--VnprYyI POLICY ExPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000.000 L FIRE DAMAGE (Any one nre) S 50,000 A COMMERCIAL GENERAL 1301644510856-CGt� CLAIMS MAnE M OCCUR :4ad:van i C , -)5/2001 05/06/2002 I MED EX A onepeRonl S 51000 PERSONAL 6 ADV INJURY 3 - ❑ I T GENERAL AGGREGATE S 11000,000 ��— GEN•L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S ❑ POLICY ❑ Plzo- LOC AUTOMOBILE LIABILITY ANY AUTO I COMBINED SINGLE LIMIT (Eaaccdent) $ l,OOD.000 8 ® ❑ Cl ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS CLaz019a- 2 Vans 3 CaT7l :a ". '.i/2001 08/06/2002 BOOILY INJURY (Per nelson) S T V BODILY INJURY (Per accldeal) $ PROPERTYOAMAGE S ❑ GARAGE LIABILITY AUTO ONLY , EA ACCIDENT S OTHER THAN EA ACC 3 ❑ ANY AUTO S I AUTO ONLY' AGO HfALrAIB LIABILITY ❑ OCCUR C® CLAIMS MADE EACH OCCURRENCE 3 1, 000, 000 AGGRCGATE $ 31000,000 C &M-810840 - Meo'v;zL1/2001 00/06/2002 3 DEDUCTIBLE $ ❑ RETENTION S a — WORKERS COMPENSATION AND t I WC STATUS OTH- E.L. EACH ACCIDENT S EMPLOYERS' LIABILITY __ E L. DISEASE • EA EMPLOYES _.... E.L. DISEASC• - POLICY LIMIT S j D OTHER Directors & Officers Liability ND01013503 0z-19/2001 03/09/2002 Each Claim 11000,000 Aggregate 1.000,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESrEXCLUSIONS ADDEO 7Y =,'GORSE;' )4T. -p'AL PROVISIONS CERTIFICATE HOLDER LLAJI ADOITIONAL INSURED; Monroe County BOCC 5100 College Road Key West FL 33040- _ •"r�klLA1WIV _ '::.0 ANY OF THE ABOVE OESCRIBED POLICIES 9E CANCELLEO sefORE YNE ExMRAT(ON THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN ^. TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 30 SHALL NO OELIGATIO OR LIABILITY OF ANY IfIND UFfN THE IN�URER, ITS AGENT OR `[a-' J7IZED REPRESENTATIVE ZO-5 (7/97) COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 01 A INFORMATION PAGE Insurer: Producer: Agent# 1130 Harbor Specialty Insurance Company Isaksen Insurance, Inc. C/o AmeriComp Insurance Services P.O. Box 430534 P.O. Box 9130 Big Pine Key, FL 33043 Daytona Beach, FL 32120-9130 (Carrier Code: 35270) 024 Carrier Policy #: 099000002283102 Carrier Prior Policy #: NEW 1. -The Insured: Rural Health Network of Monroe County FL Type of Business: Corporation Mailing Address: P.O. Box 4966 Key West, FL 33041-4966 Other workplaces not shown above: Fein: 650474953 SEE SCHEDULE OF OPERATIONS Risk ID: 2. The policy period is from 12:01 a.m. on 5/07/2001 to 12:01 a.m. on 5/07/2002 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: FL 1� B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOA(04/92) WC000414(07/90) WC090606(11/98) WC990610 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 3,600.00 Minimum Premium $ 261.00 Expense Constant $ 200.00 Countersigned by COMMERCIAL AUTO COVERAGE PART CA 00 03 12 93 0198 BUSINESS AUTO DECLARATIONS ❑ The Declarations ewal of Number' include a second part designated ONE "Part 2". its Coverage Part is effective the inception date of the policy unless another date is indicated below. (The following information required only when this Coverage Part is issued subsequent to preparation of policy.) Policy No.: CL220776 Named Insured: RURAL HEALTH NETWORK OF MONROE COUNTY INC Additional Premium: (From endorsement date to Pocky Expiration) Effective Date: August 06, 2001 Countersigned by: Authorized Representative Endorsement No.: Form of Business: ❑ Individual ❑ Partnership ® Corporation ❑ Other IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU ROVIDE THE INSURANCE AS STATED IN THIS POLICY. TO P _ T LIABILITY 7 S 1,000,000 CSL $ 5,719.00 PERSONAL INJURY PROTECTION (P.I.P.)tt 7 SEPARATELY STATED W EACH P.I.P. END. MINUS S NIL Deductible $158.00 ADDED P LP (or eq Mft t added N"Id car.) SEPARATELY STATED IN EACH ADDED P.LP. ENDORSEMENT f PROPERTY PROTECTION INS. (P.P.L) SEPARATELY STATED IN THE P.P.L ENDORSEMENT MINUS Mchrgan only) S Deductible FOR EACH ACCIDENT $ AUTO MEDICAL PAYMENTS = _ UNINSURED MOTORISTS (UM) S f UNDERINSUREDMOTORIST c,,1nr1iecd $ s ACTUAL S 1000 Ded. FOR EACH COVERED AUTO, BUT NO DED. $ 847.00 a COMPREHENSIVE COVERAGE 7 CASH VALUE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. t1t OR COST OF 71 SPECIFIED CAUSES OF LOSS COVERAGE REPAI, $25 Deductible FOR EACH COVERED AUTO FOR LOSS S WHICHEVER CAUSED BY MISCHIEF OR VANDALISM ttt U H COLLISION COVERAGE 7 IS COLLISION S 1000. Deductible FOR EACH COVERED AUTO tit $844.00 i TOWING AND LABOR �e S for each disablement of a auto $ FORMS AND ENDORSEMENTS APPLYING TO THIS COVERAGE PART AND MADE PART OF THIS POLICY AT TIME OF ISSUEt: See Attached Schedule of Endorserttents PRE AM FOR ENDORSEMENTS S ESTIMATED TOTAL PREMIUM 1$9,265.00 tt(or e9xvakft No4aut c w) tttSee ITEM FOUR for hied or bonowed 'autos'. overed DESCRIPTION PURCHASED TERRITORY: Town & State Where the Covered Auto Year Modet Trade Name: Body Type Odgirw Cost New PAW NEW(N) Auto will be p kKpally garaged No. Serial Number (S). Vehicle Wentifiealion Number (V9Q Cost & USED(U) 1 1 See Form EM0115 2 3 4 5 CLASSIFICATION overed Radius of Business use Size GVW. GCW Pr'M Rating Secondary Except for Im" al physical damage loss's payable to you and the loss Auto O�a� ��"�° or Vehicle Age Factor Rating Code payee named below as itte nnis may appear at the time of the loss No. (in 1 oar Sea"CaPaciy �• �• Damage Factor 1 See Form EM0115 2 3 4 5 *Entry optional if shorn in Common Policy Declarations. tFonns and Endorsements applicable to this Coverage Part omitted if shown elsewhere in the policy. THESE DECLARATIONS ANDTHE COMMON POLICY DECLARATIONS, IF APPLICABLE, TOGETHERWITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. JDL 190 (11)(1}X-8 (Ed.12-93) Includes copyrighted material of Insurance Services Office, Inc., with its pwrtission. Copyright, Insurance Services OtTtce's, Inc.,1993 *Entry optional if shorn in Common Policy Declarations. tFonns and Endorsements applicable to this Coverage Part omitted if shown elsewhere in the policy. THESE DECLARATIONS ANDTHE COMMON POLICY DECLARATIONS, IF APPLICABLE, TOGETHERWITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. JDL 190 (11)(1}X-8 (Ed.12-93) Includes copyrighted material of Insurance Services Office, Inc., with its pwrtission. Copyright, Insurance Services OtTtce's, Inc.,1993 § u k a 0 a 0 0 k «88 a # 2 2 - ` 00 _ _ _ _ _ _ _ k _ k _ _ _ _ - - - 2 - 44 I � 2 2 o a E a § 7 # @ @ $ # 2§§■ - - ®®- ®- - - ®- - - - - - - - - - - - - - - - - - - - - ._ / 2E # # § � a« 2 - _ ® - ® ® - E Mƒ E ® _ ® ® - _ _ - - - - ® to I - 1 - - ¥0 a - - - - - 40 - - - - - - - - ® - 40 CL In E I # # a f a § © ■ CL $ 4 _ f - ® - - - - - W.- - E 1 ^ E e _ _ _ to _ _ _ _ (a _ _ _ _ _ _ _ _ _ _ _ ®®- - El , c Jo ) \ $ _ a . _ � wv e ■ J _ � _ _ _ _ _ - ® - - fa - � § w ■ ■ ■ ■ E c, § §Ul-j � 0 s s .�_ ® B 0 S U. � ,$ � k § k 9 § # _ # . f �2 � 7 \ �■ ,� � u |�f \ k § 21 cc k § w� I � � THE BURLINGTON INSURANCE COMPANY I 238 INTERNATIONAL ROAD BURLINGTON, NORTH CAROLINA 27215 COMMERCIAL LINES POLICY COMMON POLICY DECLARATIONS Policy No. B 01 6 4 Q5 1 0 8 5 6 Renewal of Number : B01640510347 Named Insured and Mailing Address (No., Street, Town or City, County, State, Zip Code) RURAL paULLTB NETWORK OF NONROB COUNTY INC P O BOX 4966 KEY WEST-MONROS FL 33040 Policy Period: From 08/06/01 to 08/06/02 address shown above. Business Description: MEDICAL OFFICES at 12:01 A.M. Standard Time at your mailing IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. ' PREMIUM Commercial Property Coverage Part`- _:f S NOT COVERED a Commercial General Liability Coverage Part S 1,250.00 Commercial Inland Marine Coverage Part S NOT COVERED Garage Coverage Form S NOT COVERED Liquor Liability Coverage Form S NOT COVERED ISAKSEN INS. �i�wT'aa S NOT COVERED BIG PINE KEY FL i"s ``" J e S NOT COVERED TOTAL PREMIUM (Payable at policy inception): S 1,250.00 POLICY FEE S 35.00 SURPLUS LINES TAX S 64.25 .3% FSLSO S 3.86 Y a,:y - u -- I l c ht of F. -:; sty fur ob!igaticn of an TOTAL AMOUNT DUE : S 1,353.11 Ins oivent Unlicensed Insurer." Form(s) and Endorsements) made a part of this policy at time of issue*: BJP 190-0-X 02/98,CL 150 11/85,BG-1-152 06/94,IL 00 03 04/98,11. 00 17 11/98,IL 00 21 04/98,BG-1-015 08/00 *Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations. KW Countersigned: 09/10/01 HULL & COMPANY, INC.`�°+�- By Authorized Representative THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. JOL 190 (0)-X (Ed. 11-85) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1983, 1984. ORIGINAL COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Policy No. B 01640510856 Effective Date: 08/06/01 ,** 12:01 A.M., Standard Time LIMITS OF INSURANCE General Aggregate Limit (Other Than Products --Completed Operations) S 1,000,000.00 Products --Completed Operations Aggregate Limit S SEE FORM BG-G-173 Personal and Advertising Injury Limit S EXCLUDED Each Occurrence Limit $ 1,000,000.00 Fire Damage Limit $ 50,000.00 Any One Fire Medical Expense Limit S 5,000.00 Any One Person RETROACTIVE DATE (CG 00 02 only) Coverage A of this Insurance does not apply to "bodily injury" or "property damage" which occurs before the Retroactive Date, if any, shown here: (Enter Date or "None" if no Retroactive Date applies) BUSINESS DESCRIPTION AND LOCATION OF PREMISES Form of Business: Individual Joint Venture Partnership X Organization.(Other than Partnership or Joint Venture) Business Description*: MEDICAL OFFICES Location of All Premises You Own, Rent or Occupy: POINCIANA PLAZA BLDG 1623, UNITS 2 & 4, KEY LEST FL 33045 PREMIUM Classification MEDICAL OFFICES - INCLUDING PRODUCTS AND/OR COMPLETED OPERATIONS. THESE PRODUCTS AND/OR COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT. Code No. Premium Basis Pr/Co 66561 MEDICAL OFFICES - INCLUDING PRODUCTS AND/OR 66561 COMPLETED OPERATIONS. THESE PRODUCTS AND/OR COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT. 600 INCL. PREMIUM BASIS = AREA 600 INCL. PREMIUM BASIS = AREA Rate Advance Premium All Other Pr/Co All Other Total Advance Premium 97.66 SINCL. 5217.00MP 97.66 INCL. 216.00MP S 0.00 S 1,250.00 FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the policy) Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue: CL 170 01/86,CG 00 01 07/98,CG 03 00 01/96,BG-C-2-CW 03/01,BG-G-004 09/99,BG-G-007 09/99,BG-G-041 09/99,BG-6-042 04/00, BG-G-066 04/92,BG-G-179-FL 11/96,BG-G-173-FL 09/96,CG 20 11 01/96,CG 20 12 07/98,CG 21 36 01/96,CG 21 38 11/85, CG 21 60 09/98,CG 22 44 07/98 *Information omitted if shown elsewhere in the policy. **Inclusion of date optional. THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD CL 150 (Ed. 11-85) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1983, 1984 Policy No. SM-810840 M EVANSTON INSURANCE COMPANY Prev. No. M-8 724912955 DECLARATIONS - PROFESSIONAL LIABILITY INSURANCE FOR SPECIFIED MEDICAL PROFESSIONS Claims Made Coverage: The coverage afforded by this policy is limited to liability for only those claims that are first made against the insured during the policy period or the optional extension period, if purchased. In consideration of the payment of premium, in reliance upon the statements in the application attached hereto and made a part hereof and subject to all the terms of this policy, the Company agrees with the Named Insured as follows: 1. NAMED INSURED: RURAL HEALTH NETWORK OF MONROE COUNTY, INC. The Named Insured is: a: Corporation 2. BUSINESS ADDRESS OF THE INSURED: r•r.- A. T, pa c, n. n 1623-D SPAULDING COURT P°°3 P.O. BOX 4966 KEY WEST, FL 33041-1630 ` 3. PROFESSION OF THE INSURED: Family Practice Clinic and —Mobile —Clinic B►o 4. POLICY PERIOD: From Augur# 6, 2001 to August �6, 2002 12:01 A.M. Standard Time at address of Insured stated above. o 5. RETROACTIVE DATE: August 6, 1999- 3�o zoo t 6. LIMITS OF LIABILITY: F $ 3�5 o�laB.a5 The liability of the Company for each claim including claim.:.. expenses shall not exceed $ 1,000,000 and, subject to that limit for each claim, the total limit of the Company's liability for all claims including claims expenses shall not exceed in the aggregate $ 3,000,000 7. DEDUCTIBLE: Applicable to each claim, including claim expenses $ 2,500 8. PREMIUM FOR POLICY PERIOD- $ 5,330.00 5% FL Surplus Lines Tax �SLIO SERVICE FEE (� I O ��.�„ 266.50 .3% FL Service Fee 1599 99 9. OPTIONAL EXTENSION PERIOD: 12 months @ 125% of the full annual premium hereunder. 10. The Insured is not a proprietor, superintendent, executive officer, director, partner, trustee or employee of any hospital, sanitarium, clinic with bed -and -board facilities, laboratory, or any business enterprise not named in Item 1 hereinabove, except as follows: None Page 1 LA DRD,� CERTIFICA', _ OF PRODUCER DATE(MM/DD/YY) LIABILITY INSUF� Is Is s Insurance Inc ,NCE 10/01/2002 THIS CERTIFICATE IS ISSUED AS A Overseas Highway Big Pine MATTER OF INFORMATION ONLY AND COER THISNFERS NO RIGHTS UPON THE CERTIFICATE HO LD HOLDER. THIS CERTIF1 E Key„ FL 33043 ALTER THE COVERAGE AFFORDED BY OES NOT ND, EBELOW. P:305-872-0097 F:305-872-1005 T POLICIES INSURED INSURERS AFFORDING COVERAGE Rural Health Network of Monroe P. O. Box 4966 INSURER A: HULL & COMPANY/Burlington Insurance Co RE : Poinciana Plz Bld 1623 4d INSURERS: Hull & Company/Empire Fire & Marine Ins INSURER C: Key West FL 33045- INSURER D: COVERAGES INSURER E: 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 MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJ WHICH THIS CERTIFICATE MAY BE ISSUED OR POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS..ECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH NSR TYPE OF INSURANCE POLICY NUMBER GENERAL LIABILITY POLICY EFFECTIVE POLICY EXPIRATION A ❑ COMMERCIAL GENERAL LIABILITY 164BO50179 ❑ CLAIMS MADE In OCCUR LIMITS EACH OCCURRENCE 08/06/2002 08/06/2003 $ 1,000 000 FIRE DAMAGE (Anyone fire) $ 50,000 ❑❑ MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY 3 GEN'L AGGREGATE LIMIT APPLIES AUTOMOBILE LIABILITY ANY AUTO B j ALL OWNED AUTOS SCHEDULED AUTOS CL 220922 HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY ❑ ANY AUTO APPROVE ❑ BY EXCESS LIABILITY OCCUR ❑ CLAIMS MADE DATE WAIVER N/A DEDUCTIBLE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OTHER PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT (Ea accident) $ 08/06/2002 08/06/2003 BODILYINJURY$ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ NAG E NT AUTO ONLY - EA ACCIDENT 1 $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ ES AGGREGATE c IDESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS HOLDER Monroe County BOCC 1100 Simonton Street Atten: Ann Mytniki Key West FL 33040- (305) 295-3672 FAX E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT 1,000,000 11000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATIO OR LIAB LITY OF ANY Y KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES 11 f I Co, 1 UAI t (MM/UU/T T) AC CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE 11/11/2003 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Isaksen Insurance Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 30233 Overseas Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Big Pine Key„ FL 33043 P:305-872-0097 F:305-872-1005 INSURERS AFFORDING COVERAGE INSURED INSURER A: Hull & Co. /Burlington Insurance Company RURAL HEALTH NETWORK OF MONROE INSURERB: Hull & Co./ Colony Insurance Company P. 0. BOX 4966 INSURERC: Hull & Co./National Indemnity co. South RE: 3930 S. ROOSEVELT BLVD, KW INSURERD: Unisource/American Home Assurance Co. KEY WEST FL 33045- INSURERE: Burns & Wilcox/U.S. Liability Ins Co. COVERAGES 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 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY ® COMMERCIAL GENERAL LIABILITY 164BO50930 08/06/2003 08/06/2004 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Anyone fire) $ 50,000 MED EXP (Any one person) $ 5,000 B ❑ CLAIMS MADE FOOCCUR ❑ MP743686A 02/O1/2003 02/O1/2004 PERSONAL BADVINJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Included PRO❑ POLICY ❑ JEC ❑ LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ❑ ❑ BODILY INJURY (Per person) $ C ALL OWNED AUTOS SCHEDULED AUTOS 74APN234721 08/06/2003 08/06/2004 BODILY INJURY (Per accident) $ ❑ ■ ❑ HIRED AUTOS NON -OWNED AUTOS D Y R K PROPERTY DAMAGE (Per accident) $ ❑ GARAGE LIABILITY """' e AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ ❑ ANY AUTO ❑ m $ EXCESS LIABILITY ❑ OCCUR a CLAIMS MADE NfA EACH OCCURRENCE $ AGGREGATE $ $ ❑ DEDUCTIBLE $ ❑ RETENTION $ WORKERS COMPENSATION ANDER WC STATU- OTH- E.L. EACH ACCIDENT $ 100,000 D EMPLOYERS' LIABILITY C5209550 05/15/2003 05/15/2004 E.L. DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 E OTHER Non Profit D & O ND01013503C 03/09/2003 03/09/2004 Liability Claim 1,000,000 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY Z7ENDENT/SPECIAL PROVISIONS NOV 1 1 2003 CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION I By I SHOULD ANY OF THE ABOVE DESCRIBED POL ELLED BEFORE THE EXPIRATION Monroe County 030 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN 1100 Simonton Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Room # 268 IMPOSE NO OBLIGATIOYR LIABfLITY OF ANY KIND UPON THEE R, ITS AGENTS OR Key West (305) 292-4542 ACORD 25-S (7/97) FL 33040- (305) 295-4342 FAX ©ACORD CORPORATION 1988 CG PAL-2e-2003 TUE 123E PM 1SAKSEN INSURANOF AMERICAN HOME ASSURANCE COMPANY 13781 RURAL HEALTH NETWORK OF MONROE COUNTY FLA INC. P 0 BOX 4966 KEY WEST, FL 33040-0000 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D#F 091241021 WORKERS COMPENSATION AND EMPLOYERS LIADILITY POLICY INFORMATION PAGE 30587,21005 _ P. 0E 76119-0000 WC 520-95-50 Member Companies of American International Group ExEckmVE OFFICES: 70 PINE 8TREET, NEW PORK. N.Y. 10270 Isaksen Insurance PO Box 430534 Big Pine Key, FL 33043 CORPORATION WORKPLACkS NOT SHOWN AMOVE.SEE NAdE AND ADDRESS CHEDULE - WC990610 POLM Pvtoo-12M1 A.M. inewerd wwatthe Inatmwe Ca mm 05/15/03 To 05/15/04 A. Workers Compensation Insurenoe: Pert One of the polkV applies to the Workers Compensation Law of the states listed hero: FL S. EmploVors Liability Insurance Part Two of the p*Wy applies to tM work in each state ileted in item S.A. The limits of our llvWllty under Part Two are: SodlIV IMur4 by Amidsm S 100. 00 mah sooldent Bodily Injury by Disease $ KOO. OO - pofty limit Boddv injury by Disease S 100 - OOA each employee C. Other States insurance: Part Three of rite policy applies to salter, If any, listed hers AK AL AR AZ CO CT CC DE GA HI IA ID IL 1Ithe KS KY LA MA MD ME MI MN MO MS AT NC NE NH NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI IieM s The premium for this policy will be determined b1► our Nlan'Am of Rules, ClasslNcatloni, Rates and Rating Plans ."'Am Pl. All information required below is subject to wrfication and chanfle by audit. CNseltkaMsaa Ceoe Nwnsor pawn na" T61ol Rate Per ilex OF air Ettlwa/ed Halalwa Aneual 11 2 year nNMMetIOn Aenwl Da year SEE EXTENSION OF INFORMATION PAGE - WC7754 Va axrENst: CONINAW 15IC07 WINNe APPLICAKA tY srAT91 20 FF L - -- - — V rL. TOTAL- ft-MAT® Pa8Ma1M 11 t 6 N Mdketad belsvr. Interim adlnumente of pnwaimn shall be me": ❑ ieml-Aaaeally ❑ 004terly ❑ Mealnly 11111106" PNEM M 1*008Tsim "num"l SEE ATTACHED FORM SCHEDULE - WC990612 03/27/03 PARSIPPANY 82 ks" cal* leeulno office AYttlerWq Repro MWA41re wC GO oo 01 tooeT Ih101.rr►1!f�IN Mr1V NON PROFIT PROFESSIONAL LIABILITY POLICY RENEWAL CERTIFICATE --.,..41 %-%,ILlima« to cur exp=2 roll UNITED STATES LIABILITY INSURANCE COMPANY WAYNE, PENNSYLVANIA In consideration of the renewal premium stated below, expiring Policy Number ND01013503C is renewed for the Policy Period stated below, subject to all the terms and conditions of the expiring Policy, except as otherwise specified in the CHANGES FROM EXPIRING POLICY section of this Certificate. The Company will issue a complete copy of this Policy upon receipt of a written request from the Insured. The New Policy Number is ND01013503D . The Application (if any) for this renewal, and all previous Applications made to the Company for this insurance, including any material submitted therewith, shall be made a part of this Renewal Policy as if "APPLICATION." physically attached hereto. PLEASE REFER TO YOUR POLICY FOR THE DEFINITION OF POLICY DECLLA 'RATIONS ITEM I. PARENT ORGANIZATION AND PRINCIPAL Rural Health Network of Monroe County Florida, Inc. P.O. Box 4966 Keywest, FL 33040 ITEM II. POLICY PERIOD: (MM/DD/YYYY) FROM 3/9/2004 TO 3/9/2005 TU7Q nnr rnv � -.�rr.,�,.,.� .. -)AT' E 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS SHOWN inn T- i vW11Nki k-UVbKAUE PARTS FOR WHICH LIMITS OF LIABILITY ARE INDICATED. Coverage Part A. Non Profit Directors and Officers Liability ITEM III. LIMITS OF LIABILITY: $1,000,000 EACH CLAIM Not Covered FIDUCIARY LIABILITY LIMIT $1,000,000 IN THE AGGREGATE ITEM IV. RETENTION: $0 EACH CLAIM ITEM V. PREMIUM: $3,156 Coverage Part B. Employment Practices Liability ITEM III. LIMITS OF LIABILITY: $1,000,000 EACH CLAIM $1,000,000 IN THE AGGREGATE ITEM IV. RETENTION: ITEM V. PREMIUM: $0 EACH CLAIM $246 CHANGES FROM EXPIRING POLICY NUMIi¢3g Dunaway Endorsements Added: DO-273 3820 Northrlalers3 Producing Agent4ivd.. 5 + _-rsrnpa, FL 336124 Adds__ �o "'--oX� a7��uaCC-t[��� (04-02) Fair Labor Standards Act, Exclusion City —�1- _ x14_ This insurance is issued pursuant to ihc� Florida Surplus Ling, i_ay 'ersons ls5sursc3 b not have the l,rot�t, y St LinesAct Date Issued: 3/10/2004 Agent: BURNS & WILCOX, -rPius t Carrie LTD. (79 16'J EneI®CXI�'`nr ` 'y'~ ` Pr a-nce Guar" rnen,•F,th,,otion By USL-DOD C>FRT (11/97) Authorized Representativ UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This Endorsement modifies insurance provided under the following: NON PROFIT DIRECTORS & OFFICERS LIABILITY AND EMPLOYMENT PRACTICES LIABILITY FAIR LABOR STANDARDS ACT, MISCLASSIFICATION OF STATUS AND MISREPRESENTATION OF STATUS EXCLUSION In consideration of the premium charged, it is agreed that the following provision is added to DO- 101 (04/00), Section IV, EXCLUSIONS: L. The Company shall not be liable to make payment for Loss or Defense Costs in connection with any Claim made against any Insured for: (1) actual or alleged violations of the Fair Labor Standards Act (except the Equal Pay Act), any amendments thereto, or any similar provisions of any federal, state or local law; or (2) improper wages or wage disputes due to misclassification of Employees as exempt or non exempt; or (3) misrepresentation involving any Employee's status as exempt or non exempt. All other terms and conditions of this Policy remain unchanged. This endorsement is a part of Your Policy and takes effect on the effective date of your Policy unless another effective date is shown. DO 273 (4/02) Page 1 of 1 ACCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 07/27/2004 PRODUCER Isaksen Insurance Inc 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 30233 Overseas Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE Big Pine Rey„ FL 33043 P:305-872-0097 F:305-872-1005 INSURED INSURERA: UNISOURCE INSURERB: Rural Health Network of Monroe INSURERC: P. O. BOX 4966 RE:Poinciana Plz Bld 1623 4d INSURERD: Key West FL 33045- INsuRERE: COVERAGES 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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY ❑ COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE ❑❑ OCCUR ❑ EACH OCCURRENCE $ FIRE DAMAGE (Any one fin:) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ ❑ PRODUCTS - COMP/OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO- ❑ LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS r �� �Y DATE -'— MIA F R A WA1J� ' A y .GFVIrCNI_ DES r _n COMBINED SINGLE LIMIT (Ea aocident) $ BODILY INJURY (Per person) $ ❑ ❑ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ ❑ GARAGE LIABILITY ❑ANY AUTO ❑1 '6 C fj, AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ AC768-59-80 EXCESS LABILITY ❑ OCCUR ❑❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LABILITY 05-15-2004 05-15-2005 EACH OCCURRENCE $ AGGREGATE $ S $ WC STATU- OTH- $ _IJM E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 3.00,000 E.L. DISEASE - POLICY LIMIT $ 5,000,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES,EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER I L& I ADDITIONAL INSURED; INSURER LETTER: a.nna+c�u� r rvr� Monroe County Board Of County Commisioners 1100 Simonton St. Key West FL 33040- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 03 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OfjpIIABILITY OOP ANY KPI�UPON THUWMER, ITS AGENTS OR ACORD 25S CC ©ACORD CORPORATION 1988 DATE (MM/DDffYYY) AGLOW. CERTIFICATE OF LIABILITY INSURANCE 11/05/2004 305) 872-0097 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ( ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Isaksen Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 30233 Overseas Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 430534 Bi Pine Re FL 33043- INSURERS AFFORDING COVERAGE NAIC # INSURER A UNAMARK/ COLONY GROUP INS INSURED RURAL HEALTH NETWORK OF MONROE COON INSURER B: NATIONAL INDFd"IIdITY INS. P. O. BOX 4966 INSURERC: RE: 3930 S. ROOSEVELT BLVD , KW INSURER D: AMV THE POLICIES OF INSURANCE LISTtIJ ntwvr rvwc Dv- i" -- • • •- --__. ___ERTIFICATE MAYBE ISSUED UK Trr- REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. A-M^-ATC I lUrrc CMt um MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR — _ N TYPE OF DOURANCE A X GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR GENT. AGGREGATE LIMIT APPLIES PER: rl POLICY F71JPERLOC B AUTOMOBILE LUUULRY ANY AUTO ALL OWNED ALTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY ANY AUTO EXCESSAMRELLA LIABILITY OCCUR El CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND LIABILITY EMPLOYERS' ANY PROPRIETORIPARTNER/EXECUTNE OFFryC EXCLUDED? N yea, daa, .i andW SPECIAL PROVISIONS below OTHER MP743686A 74 APN 290694 - 0158 02/01/2004 02/01/2005 EACH OCCURRENCE $ 1,000,000 ED PREMISES Ea oceurrenoe PREMISES $ 50,000 MEDExp ;; S 5,)00 PERSONAL E ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 1,000,000 PRODUCTS = COMPIOP AGG $ 08/06/2004 08/06/2005 COMBINED SINGLE LIMIT (Ea acd&M) $ 1,000,000 BODILY INJURY (Per Pew) S BODILY INJURY (Per accident) S EEI PROPERTY DAMAGE (Per accident) � $ S V , d : i l'. AUTO ONLY - EA ACCIDE S / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ AGGREGATE $ 9N3W3��Rt'I' AP P9� u B, RHKiklAr BY _._. .. .. DATE, G MA-lE.L.I _ t.,. / / E.L.I PROVISIONS DORSEMENTISPECUAL DESCRIPTION OF OPERATK)NSILOCATIONSNEHK:LE&ERCLUSIONS ADDED BYGr— /VI (305) 292-4542 Monroe County BOCC 1100 Simonton Street M (305) 295-4364 FX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR UABIUTY OF ANY KIND UPON THE 33040- ACORD 25 (2001108) V INS025 (0108).05 ELECTRONIC LASER FORMS, INC. - a ACORD CORPORATION 1988 Page 1 of 2