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insuranceACC PR CERTIFICATE OF LIABILITY INSURANCE llll.,, -' DATE(MM/DD/YYYY) 1 06/22/2015 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). PRODUCER Advanced Professional Insurance Ser CONT NAMEACT Joseph Santiago, CPIA, CPII, PIAM PHON o (954) 725-6112 ac No): (954) 725-6115 A-MAILnnRFSS' jsantiago@advancedprofessional.com 240 Lock Road INSURERS AFFORDING COVERAGE NAIC # Deerfield Beach, FL 33442 INSURER A : Lancet Indemnity Phone (954) 725-6112 Fax (954) 725-6115 INSURED INSURER B : INSURER C : Gilbert Shapiro, MD 540 Truman Ave. INSURER D : Key West FL 33040 INSURER E : INSURER F : r^nvcoer_Fc 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. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF MM/DD/YYYYI POLICY EXP IMMIDDIYYYY) LIMITS ❑ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ 250,000.00 DAMAGE PREM SESOEa occu RENTED $ MED EXP (Any one person $ A Medical professional Liability LRO91289001415 07/01/2015 07/01/2016 ❑ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 750,000.00 PRODUCTS - COMP/OP AGG $ PRO- ❑ POLICY ❑ ECT ❑ LOC ❑ OTHER $ AUTOMOBILE LIABILITY INED EO ac.denlSINGLE LIMIT $ BODILY INJURY (Per person) $ ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS C HIRED AUTOS ❑ NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ AGGREGATE $ ❑ EXCESS LIAB ❑CLAIMS-MADET ❑ DED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) R- ❑ PTR T ❑ ER $ N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Specialty: Family Practice - No Surgery Endorsement: Stephanie A. Gallaher, ARNP B APPRO 0W�EMj 1 ' C��- ;t* wn i (t 2- 1,rKI lrm AlC nVLUCR p/ I ; % I U.1n.', -. Monroe County Board of County Commissioners 1100 Simonton St., Sine CAJ Nd o E Nnr 5101 Key West, FL 33040-U8038 80-4 0311.4 ACORD 25 (2014/01) OF 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 TtltftS-LUT4 AVVKU I.VRr'VKA 1IVn. An rlynw lesaerv�a. The ACORD name and logo are registered marks of ACORD T ® ACC?R o CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 07/25/2016 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 NAME: Joseph Santiago Advanced Professional Services A NE.. EXt : (954) 725-6112 AJC No): (954) 725-6115 ADDRESS: Joseph@advancedprofessional.com 240 Lock Road INSURER(S) AFFORDING COVERAGE N NAIC # INSURER A: LANCET INDEMNITY RRG 13014 Deerfield Beach FL 33442 INSURED INSURERS: C" INSURER C : Gilbert Shapiro, MD INSURER D : tv 540 Truman Ave. INSURER E : In C-7 INSURER F : Key West FL 33040 V ♦/� GrV1V GJ vim. �... ...�.. � .. �...��. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABPVE FOR TOK POLICY PERIOD T TO WQCH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WaH RESPE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS *JBJECT TCWL 71HR TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE A POLICY NUMBER MDDLfSM MIDDIIYYYYLICYEFF MM/ D//YYYY POLICYEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMA ET0 RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ -COMP/OP AGG $ RO POLICY❑JPECT❑LOC OTHER: SINGLE LIMIT (Ea accident) $ AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NO OWNED PROPERTY DAMAGE Per accident $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ PER OTH- $ WORKERS COMPENSATION STATUTE ER E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECLMVE E.L. DISEASE - EA EMPLOYE $ OFFICERIMEMBER EXCLUDED? ❑ (Mandatory In NH) N / A E.L. DISEASE -POLICY LIMIT $ If es, describe under DESCRIPTION OF OPERATIONS below $250,000 Per Claim q Physicians and Surgeons LR091289001415 07/01/2016 07/01/2017 $750,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Specialty: Family Practice. Endorsements: New Truman Medical Center, and Stephanie A. Gallaher 191 EMEM/A 4APPRO _1( _ _ le CERTIFICATE HOLDER l.AN%,rLLAIIVIv SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Monroe County BOCC 1111 12th St AUTHORIZED REPRESENTATIVE Key West FL 33040 %W 1.7o0'LV rY tea.Vrw vv..r v...-.,,v... .-... .y..w ........ ...... ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD