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Certificate of Insurance' a ` CVRV � CERTIFICATE OF LIABILITY INSURANCE 11 Y j * „� 8/14 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 NAM ACT Joseph SAntiago, CPIA, CPII, PIAM Advanced Professional Services PHONE 10 6 (9 4) 725 -6112 ac No) (954) 725 -6115 240 Lock Road A P -MAIL nDRESS, jsantiago @advancedprofessional.com Deerfield Beach, FL 33442 INSURERS AFFORDING COVERAGE NAIC # Phone (954) 725 -6112 Fax (954) 725 -6115 INSURER A: Lancet Indemnity RRG INSURED INSURER B: Elias J. Gerth, MD 540 Truman Ave. Key West, FL 33040 COVERAG CERTIFICATE NUMBER: REVISION NUMBER: THIS INDICATED. CERTIFICATE EXCLUSIONS IS TO CERTIFY THAT THE POLICIES OF NOTW ITHSTANDING ANY REQUIREMENT, MAYBE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH POLICIES. INSURANCE THE LIMITS LISTED BELUW r1AVt tsttly iaautu TERM OR CONDITION OF ANY CONTRACT INSURANCE AFFORDED BY THE POLICIES SHOWN MAY HAVE BEEN REDUCED i U I nr_ OR OTHER DESCRIBED BY PAID wiaur%r_u iin1vI DOCUMENT HEREIN CLAIMS. a mu v - „ . - WITH RESPECT TO IS SUBJECT TO ALL THE -. -• -- WHICH THIS TERMS, INSR LTR A TYPE OF INSURANCE GENERAL LIABILITY ❑ DAMAGE COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE ❑ OCCUR ❑ Medical Professional Liability ADD UB POLICY NUMBER LR091212001354 POLICY EFF MM /DDIYYYY 05/01/2014 POLICY EXP MMIDDIYYYY 05/01/2015 LIMITS EACH OCCURRENCE $ 250,000.00 TO RENTED PREMISES Ea occurtence $ MED EXP (Any one person $ PERSONAL &ADVINJURY $ GENERAL AGGREGATE $ 750,000.00 ❑ PRODUCTS - COMP /OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS NON OWNED ❑ HIRED AUTOS ❑ AUTOS ❑ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PROPERTcident Y DAMAGE Per ac $ EACH OCCURRENCE $ $ AGGREGATE $ ❑ DED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑ T - ❑ OER $ E.L. EACH ACCENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) P ` WAIVER /A E — r CERTIFICATE HOLDER (. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioner$ i _ ?NE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • • /),CCORDANCE WITH THE POLICY PROVISIONS. 500 Whitehead St. AUTHORIZED REPRESENTATIVE Key West, FL 33040 - nASwT1Aw1 wlr tiwti�e �ncnniul� ACORD 25 (2010/05) QF The ACORD name and logo are registered marks of ACORD E (MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE D AT 05/08/2015 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). CONTACT Joseph Santiago, CPIA, CPII, PIAM PRODUCER NAME: • PHONE Advanced Professional Services (NC. No. Extl: ( 954 ) 725-6112 1 Nc, No): (954) 725-6115 E - MAIL jantiago©advancedprofessional.com 240 Lock Road ADDRESS: Deerfield Beach, FL 33442 INSURER(S) AFFORDING COVERAGE NAIC # Phone (954) 725 -6112 Fax (954) 725 -6115 INSURER A : Lancet Indemnity RRG INSURED INSURER B : Elias J. Gerth, MD INSURER C : INSURER D : 2505 Flagler 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. NOITHSTANDING ANY CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, REQUIREMENT, CONDITION HE INSU ANCE A FORD D BY THE PONCES DESCRIBED HEREIN REIN IS SUBJECT TO ALL T E SUBJECT TMS , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 6FF PAID CLAIMS. POLICY EXP ILA INSR BR POLICY NUMBER (MM POLICY /DD/YYYY) (MM /DDIYYYY) LIMITS TYPE OF INSURANCE INSR WVD EACH OCCURRENCE $ 250,000.00 GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) $ ❑ COMMERCIAL GENERAL LIABILITY ❑ 0 CLAIMS -MADE El OCCUR MED EXP (Any one person $ A LR091212001354 05/01 /2015 05/01/2016 PERSONAL & ADV INJURY $ l Medical Professional Liability GENERAL AGGREGATE $ 750,000.00 ❑ PRODUCTS- COMP /OPAGG $ GEN'L AGGREGATE LIMIT APPLIES PER $ El POLICY ❑ , PT 101 LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ BODILY INJURY (Per person) $ ❑ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED El AUTOS Li AUTOS PROPERTY DAMAGE $ NON -OWNED (Per accident) 17] HIRED AUTOS ❑ AUTOS $ ❑ ❑ EACH OCCURREN $ ❑ UMBRELLA LIAR L] OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE AGGREGATE $ $ ❑ DED ❑ RETENTION $ ❑ STATUTE ❑ ER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVEn N 1A OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ (Mandatory to NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is req d Specialty: Internal Medicine • 'PROW D i R VW; ENT L WAIVER NI YES, � • • , C r 1 '5-11',..t_ _ 1-11? CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1100 Simonton St., Suite 2 -268 AUTHORIZED REPRESENTATIVE Key West, FL 33040- 1 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) QF The ACORD name and logo are registered marks of ACORD