Certificiate of Insurance"'' ' RCERTIFICATE OF LIABILITY INSURANCE
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DATE IYYYY)
09119//19/14
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.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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).
PRODUCER
Advanced Professional Services
240 Lock Road
CONTANAME: Joseph Santiago, CPIA, CPII, PIAM
PH(AJC. ONE (954) 725E 112 FAX
A/C No): (954) 725 6115
AE-MAILDDRESS* janbago@advancedprofessional.com
INSURERS AFFORDING COVERAGE
NAIC 0
Deerfield Beach, FL 33442
INSURER A ; Lancet Indemnity
Phone (954) 725-6112 Fax (954) 725-6115
INSURED
INSURER B
INSURER C
Timothy W. Mackey, DO
INSURER D
540 Truman Ave.
INSURER E :
Key West, FL 33040
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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.
ILTR
TYPE OF INSURANCE
ADD
SUB
POLICY NUMBER
POLICYEFF
EXP
MMroD
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 250,000.00
❑ COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea occurrence
$
MED EXP (Any one person
$
A
❑ ❑� CLAIMS -MADE ❑ OCCUR
Medical Professional Liability
L1091212001739
10/02/2014
10/02/2015
PERSONAL & ADV INJURY
$
❑
GENERAL AGGREGATE
$ 750,000.00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$
PRO ❑ LOC
❑ POLICY ❑ JECT
$
AUTOMOBILE LIABILITY
OMBINED SINGLE LIMIT
Ea accident
BODILY INJURY (Per person)
$
❑ ANY AUTO
❑ AUTOS ALLOWNED ❑ AUTOS SCHEDULED
HIRED AUTOS NON OW NED
❑ ❑ AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
$
❑ ❑
❑ UMBRELLA LAB ❑ OCCUR
EACH OCCURRENCE
$
❑ EXCESS LIAB ❑ CLAIMS -MADE
AGGREGATE
$
❑ DED ❑ RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
❑ WCRSTATU ❑ OTH-
Y LIMITS ER
E.L. EACH ACCIDENT
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N / A
E.L. DISEASE - EA EMPLOYE
$
If
Iyes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Specialty: Urgent Care
NAG MENT
ZPR
A/A
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CERTIFICATE HOLDER CANCELLATION
Monroe County Board of County Commissioners
1100 Simonton St., Suite 2-268
Key West, FL 33040- `
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
V IVD*-LUTU At UKU t UKYVKA I IUIV. An rlgm5 re5erve0.
ACORD 25 (2010/05) CIF The ACORD name and logo are registered marks of ACORD