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MISSOURI HOSPITAL PLAN Endorsement No 2 This attaching clause is completed anly when this endorsement s issued after policy issuance ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY DIFFERENCE IN DEDUCTIBLES This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM Because different deductible amounts may be applicable to various coverages provided by this policy it is agreed that subject to all the terms and conditions of this policy bodily injury to a. any patient after admission and through discharge or b. any outpatient shall be deemed to result from providing or failing to provide health care services or facilities to such person and no coverage will be provided for such bodily injury under the COMMERCIAL GENERAL LIABILITY COVERAGE FORM. Form GEN 3 518 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 3 This attaching clause is completed only when this endorsement is issucd afler policy issuance ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM 1. Each employed specialist shown in the Schedule which forms a part of this endorsement shall be considered your employee and thus an insured for the purposes of Paragraph 2.a. of Section II Who Is An Insured as it relates to Coverage O. Hospital Professional Liability. 2. This insurance for each employed specialist does not apply to bodily injury which occurred a. Before the RETROACTIVE DATE shown in the Schedule for the employed specialist or b. On or afier the COVERAGE EXPIRATION DATE. shown in the Schedule for the employed specialist. 3. This insurance for each employed specialist applies to bodily injury only if a claim for damages because of the bodily injury is first made against the employed specialist a. During the policy period b. After the COVERAGE EFFECTIVE DATE shown in the Schedule for the employed specialist and. Before the COVERAGE EXPIRATION DATE shown in the Schedule for the employed specialist. 4. This endorsement does not increase the Limits of Insurance shown in the Declarations and described in Seetion IXX Limits Of Insurance ADDITIONS DELETIONS AND CHANGES 5. The Schedule for this endorsement shows one or more AUDIT PERIODS. On or before the REPORT DATE shown for each AUDIT PERIOD you must notify us in writing of a. Any employed specialist who became your employee or with whom you began a contract during the AUDIT PERIOD if you want us to provide insurance for the employed specialist continued on Page 2 Page 1 of2 Form HPL 3 505 | 2 |
b. Any employed specialist who ceases to be your employee or with whom you terminate a contract during the AUDIT PERIOD and c. Any employed specialist whose medical practice or activities have changed so that a different rating classification should apply.. If you notify us of any addition deletion or change on or before the REPORT DATE for the AUDIT PERIOD during which the addition deletion or change took place we will amend this insurance as of the date each addition deletion or change took place. L If a. You notify us of any addition deletion or change after the REPORT DATE for the AUDIT PERIOD during which the addition deletion or change took place or b. We become aware of any addition deletion or change of which you have not given us notice We will at our sole discretion a. Amend this insurance effective on either the date such addition deletion or change took place or the date we became aware of such addition deletion or change or b. Decline to amend this insurance to reflect the addition deletion or change.. Additions deletions or changes may result in an additional or return premium for the insurance provided under this endorsement. Form HPL 3 505 Page20f2 | 2 |
EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST ENDORSEMENT This Schedule forms a part of this endorsement. SCHEDULE The AUDIT PERIOD is from the first day of each month to the last day of each month and the REPORT DATE is the 15th day of the following month COVERAGR COVERAGE BFPRCTIVE EXPIRATION RRTROACTIVE RATE DRROST Employed Specialist DATE DATR DATE CLASS CLASS PREMIU Certified Nurse Midwife 75013 7 32 56 DONNELL DEANNA CNM 7 01 2015 7 01 2016 1 01 2006 SHEPARD MEGAN CNi 7 01 2015 7 01 2016 6 01 2011 Nurse Practitioner 75015 1 9324 CAMPBELL THERESA NP 7 01 2015 7 01 2016 11 09 2010 CASS CONSTANCE SUSAN NP 7 01 2015 7 01 2016 12 02 2013 COATNEY MARY ANN NP 7 01 2015 7 01 2016 8 01 2014 DODDY BRENDA K. NP 7 01 2015 7 01 2016 1 01 2013 JOHNSTON MICHAEL NP 7 01 2015 7 01 2016 7 01 2015 MOSER SANDI RN FNP 7 01 2015 7 01 2016 1 10 1996 SCHREIMAN RORI NP 7 01 2015 7 01 2016 6 01 2013 WILLIAHS LEANN E. FNP 7 01 2015 7 01 2016 8 01 2014 Physicians or Surgeons Assistant 75033 1 1933 ROMNEY LORENZO II PA 7 01 2015 7 01 2016 10 01 2009 Certified Registered Nurse Anes wo supervision 75043 2 22616 CORAZZIN GUY TONY CRNA 7 01 2015 7 01 2016 5 05 2008 GREEN ANDREW CRNA 7 01 2015 7 01 2016 9 06 2012 HODGKIN NEAL CRNA 7 01 2015 7 01 2016 9 15 2008 PETERSON PAUL J. CRNA 7 01 2015 7 01 2016 2 15 2011 Emergency Medicine No Major Surger 80102 4 123257 BRIZENDINE PAUL T MD 7 01 2015 7 01 2016 4 01 2010 HAUG DARIN L. DO 7 01 2015 7 01 2016 9 01 2012 HOFFMAN FRANCINA D 7 01 2015 7 01 2016 6 01 2015 HOWERTON PRESTON B. DO 7 01 2015 7 01 2016 5 01 2015 RALEIGH TIMOTHY BRUCE DO 7 01 2015 7 01 2016 12 01 2013 STHON GLENN W. DO 7 01 2015 7 01 2016 2 02 2015 TURNER MICHAEL 0. MD 7 01 2015 7 01 2016 2 01 2013 80153 7 499245 Surgery Obstetrics and Gynecology CARR DAVID A. MD 7 01 2015 7 01 2016 5 15 2013 SONG KAREN MD 7 01 2015 7 01 2016 7 01 2014 DEPOSIT PREMIUM 32562 9324 1933 22616 5A A 123257 DO 99245 Form HPL 3 506 Policy 1000087 Page 1 | 2 |
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EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST ENDORSEMENT This Schedule forms a part of this endorsement. SCHEDULE The AUDIT PERIOD is from the first day of each month to the last day of each month and the REPORT DATE is the 15th day of the following month COVERAGE COVERAGR RFPECTIVE EXPIRATION RETROACTIVE RATE DEPOSI Employed Specialist DATE DATE DATR CLASS Crassg PREMIUI Hospitalist Minor Surgery 80222 2 6163 CARRILLO PEARL DO 7 01 2015 7 01 2016 7 05 2010 ELFRINK MELANIE MD 7 01 2015 7 01 2016 4 01 2014 JONES KRISIY L. DO 7 01 2015 7 01 2016 8 01 2014 ROMNEY LORENZO DO 7 01 2015 7 01 2016 1 01 2008 Peychiatry Including child 80249 18 4696 FAHRMEIER MARY MD 7 01 2015 7 01 2016 4 01 2013 Family or General Practice No Surgery 80420 1 29850 OXFORD MATTHEW W. MD 7 01 2015 7 01 2016 3 01 2014 PAPRECK KERRIN T. MD 7 01 2015 7 01 2016 11 22 2010 ROMNEY LORENZO DO 7 01 2015 7 01 2016 10 01 2010 SPORLEDER CHRISTOPHER DO 7 01 2015 7 01 2016 10 08 2012 TINKER HOPE I. MD 7 01 2015 7 01 2016 8 01 2014 Urgent Care 80424 1 7253 LAIRD THOMAS R. MD 7 01 2015 7 01 2016 10 14 2013 Allied Health Professional 99999 9 150 BLACK CYNTHIA 7 01 2015 7 01 2016 9 02 2008 DEPOSIT PREMIUN 61634 6963 1B 29850 7 01 2015 7 01 2015 7 01 2015 7 01 2015 7253 150 Form HPL 3 506 Policy 1000087 Page 2 End of Endorsement | 2 |
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MISSOURY HOSPITAL PLAN Endorsement No 4 This attaching clnuse s completed only when his endorsement is fssucd aftr policy ssuance ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXTENDED REPORTING PERIOD COVERAGE FOR EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This endorsement modifies insurance provided under the following L HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM Each employed specialist shown in the Schedule which forms a part of this endorsement shall be considered your employee and thus an insured for the purposes of Paragraph 2.a. of Section II Who Is An Insured as it relates to Coverage O. Hospital Professional Liability. This insurance for each employed specialist applies only to bodily injury which occurred within the time period shown in the Schedule for this endorsement. This insurance for each employed specialist applies to bodily injury only if a claim for damages because of the bodily injury is first made against the employed specialist during the policy period. This endorsement does not increase the Limits of Insurance shown in the Declarations and described in Section IIT Limits Of Insurance. Form HPL 3 509 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE DRPOSIT PREMIUM INC This insurance applies only to a Medical Injury which occurred RATR Employed Speciali ON OR AFTER AND BEFORE crass cLass Certified Nurse Midwife 75013 7 DONNELL DEANNA CNI 10 08 2002 11 01 2005 Murse Practitioner 75015 1 BEAL MELANIE NP 11 01 2013 6 01 2015 DODDS BRENDA K. NP 12 21 2004 11 01 2012 WILLIAMS LEANN E. FNP 12 14 2013 1 01 2014 Certified Registered Nurse Anes wo supervision 75043 sA BONE CARL G. CRNA 3 03 2008 2 25 2011 BROWN BRIAN T. CRNA 2 01 2008 8 01 2008 CAFFEY BRIAN CRNA 8 25 2008 9 10 2012 CHRISTENSEN EVAN CRNA 4 28 2008 5 02 2008 DANCER JAMES J. CRNA 5 22 2008 5 23 2008 DEMINT DAVID P. JR. CRNA 8 01 2008 10 11 2010 DEMINT DAVID P. JR. CRNA 5 12 2008 5 16 2008 PRTERSON JAMES D. CRNA 3 24 2009 3 25 2009 PETERSON JAMES D. CRNA 6 23 2008 6 30 2008 PETERSON JAMES D. CRNA 5 16 2008 5 19 2008 RALSTON WALLACE E. CRNA 10 11 2010 2 25 2014 Emergency Medicine No Major Surgery 80102 4 ALT SUZANNE E. DO 2 12 2010 2 13 2010 ALT SUZANNE E. DO 1 05 2010 1 30 2010 ALT SUZANNE E. DO 12 11 2009 12 12 2009 ALT SUZANNE E. DO 10 15 2009 11 16 2009 BECK JOKN B. JR MD 11 01 2010 11 05 2010 BECK JOBN B. JR MD 8 22 2010 9 01 2010 BLAKEMAN XAREN L. MD 5 25 2004 8 02 2004 BLAKEMAN KAREN L. MD 5 10 2004 5 12 2004 BROWN MICHAEL 8. MD 2 10 1999 11 26 2006 DAVIS CARL RICHARD MD 10 08 2009 10 09 2009 DAVIS CARL RICHARD MD 3 06 2009 5 01 2009 DAVIS CARL RICHARD MD 2 02 2009 2 10 2009 DIEHL JEFFERY C. MD 9 16 2008 4 01 2010 INe nan nan nan nan 75015.0 INe nan nan nan nan 75043.0 5A 2 25 2011 8 01 2008 9 10 2012 5 02 2008 5 23 2008 10 11 2010 5 16 2008 3 25 2009 6 30 2008 5 19 2008 2 25 2014 e nan nan nan nan 80102.0 2 13 2010 1 30 2010 12 12 2009 11 16 2009 11 05 2010 9 01 2010 8 02 2004 5 12 2004 11 26 2006 10 09 2009 5 01 2009 2 10 2009 4 01 2010 Form HPL 3 510 Policy 1000087 Page 1 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE Tais insurance applies only to a Medical Tnjury which occurred ON OR AFTER AND BEFORR Ccrass 8 14 2008 9 06 2008 7 09 2008 7 24 2008 5 23 2008 5 26 2008 10 05 2006 11 27 2006 4 25 2006 4 26 2006 11 26 2006 11 04 2007 4 01 2005 1 01 2007 2 05 2005 3 31 2005 12 03 2004 1 28 2005 11 12 2004 11 25 2004 10 09 2004 10 25 2004 8 21 2004 8 29 2004 12 01 2012 4 27 2013 7 01 2012 11 01 2012 3 31 2011 6 01 2012 2 16 2011 3 18 2011 12 08 2010 1 02 2011 10 29 2010 11 22 2010 9 26 2010 9 28 2010 7 07 2010 8 21 2010 6 05 2010 6 25 2010 2 04 2010 5 24 2010 11 01 2009 12 27 2009 10 17 2009 10 22 2009 9 11 2009 9 29 2009 8 28 2009 8 30 2009 5 15 2007 5 16 2007 2 20 2007 4 11 2007 1 11 2007 1 22 2007 12 07 2006 12 22 2006 11 09 2006 11 19 2006 10 09 2006 10 28 2006 9 22 2006 9 27 2006 7 08 2006 9 01 2006 6 17 2006 19 2006 6 05 2006 6 07 2006 DEPOSTT PREMIUM Employed Specialist DIFHL JEFFERY C. MD DIEHL JEFFERY C. MD DIEHL JEFFERY C. MD DUCKWORTH DANA H. DO EDDLEVAN FRANK JR MD ENGLER STEPHEN R. DO FOTOPOULOS CHRIS K. MD FOTOPOULOS CHRIS K. MD FOTOPOULOS CHRIS K. MD FOTOPOULOS CHRIS K. MD FOTOPOULOS CHRIS K. MD FOTOPOULOS CHRIS K. MD FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO FUNK SANDRA E. DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO GARRISON KYLE DO Form HPL 3 510 Policy 1000087 Page 2 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a Medical Injury which occurred RATE ON OR APTER AND BEFORE CLASS cLass 02 2011 12 30 2012 4 25 2006 4 27 2006 1 01 2013 2 01 2013 7 15 2010 7 16 2010 9 17 2006 9 18 2006 7 21 2006 7 23 2006 12 01 2011 1 01 2012 9 01 2011 10 01 2011 5 01 2011 6 01 2011 2 05 2011 2 07 2011 12 17 2010 12 20 2010 9 25 2010 9 27 2010 7 10 2010 7 26 2010 5 29 2010 6 06 2010 4 24 2010 4 26 2010 3 13 2010 3 21 2010 1 05 2010 2 01 2010 12 11 2009 12 21 2009 9 27 2009 9 28 2009 8 29 2009 8 31 2009 7 26 2009 7 27 2009 5 07 2009 5 23 2009 4 25 2009 4 27 2009 1 31 2009 2 14 2009 12 26 2008 12 29 2008 1 01 2007 9 16 2008 12 02 2006 12 31 2006 9 30 2006 11 24 2006 7 01 2006 9 15 2006 6 17 2006 6 19 2006 5 27 2006 5 30 2006 4 28 2006 4 30 2006 4 01 2006 4 03 2006 3 11 2006 3 15 2006 2 11 2006 2 19 2006 1 21 2006 1 23 2006 DEROSIT PREMIUM Employed Specialist GREGORY REUEL DO GUAN LEI MD GUPTA DEVINDER GUPTA DEVINDER GUZON JOAQUIN JOAQUIN GuzoN HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG HAUG DARIN DARIN DARIN DARIN DARTN DARIN DARIN DARIN DARTN DARIN DARIN DARIN DARIN DARIN DARIN DARTH DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN DARIN L. Ley L. L. L. Lo L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. P. D P. MD MD 1D Do Form HPL 3 510 Policy 1000087 Page 3 | 2 |
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DEPOSIT PREMIUM EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a Medical Injury which occurred RATE ON OR AFTRR AND BEFORE cLASS cLass 12 25 2005 12 27 2005 12 03 2005 12 05 2005 11 12 2005 11 14 2005 10 28 2005 10 31 2005 9 03 2005 9 05 2005 10 2005 6 12 2005 11 04 2007 6 01 2008 10 17 2007 10 19 2007 1 26 2015 5 01 2015 5 01 2013 7 25 2013 12 24 2012 1 01 2013 4 01 2014 3 01 2015 1 01 2014 3 01 2014 5 01 2013 12 01 2013 1 01 2013 4 01 2013 12 01 2011 1 01 2012 9 01 2011 11 01 2011 5 01 2011 6 01 2011 6 01 2008 3 31 2011 2 15 2008 2 19 2008 6 04 2004 6 28 2004 4 28 2004 5 26 2004 2 11 2002 1 26 2004 8 24 2012 9 01 2012 2 05 1999 6 30 2013 8 05 2012 9 01 2012 10 21 2013 12 01 2013 9 10 2004 9 28 2004 8 06 2004 9 02 2004 6 13 2004 7 28 2004 2 08 2004 4 20 2004 4 21 2014 7 01 2014 10 07 2001 4 01 2004 2 19 2007 1 02 2011 11 01 2013 12 01 2013 3 31 2013 4 01 2013 Employed Specialist HAUG DARIN L. DO HAUG DARIN L. DO HAUG DARIN L. DO HAUG DARIN L. DO HAUG DARIN L. DO HAUG DARIN L. DO HENRY MICHAEL P. DO HENRY MICHAEL P. DO HOFFMAN FRANCINA MD HOFFMAN FRANCINA MD HOFFMAN FRANCINA HMD HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO HOWERTON PRESTON B. DO JONES MICHAEL MD JONES MICHAEL MD JONES MICHAEL MD KATUKOORT SHASHI MD LAIRD THOMAS R. MD LONEY JOHN M. MD MILLER MICHAEL F. MD MILLS DOUGLAS J. MD MILLS DOUGLAS J. MD MILLS DOUGLAS J. MD MILLS DOUGLAS J. MD OXFORD DAVID MD PAPRECK KERRIN T. MD PATTERSON JAMES L. DO RILEY MEGAN E. DO RILEY MEGAN E. DO Form HPL 3 510 Policy 1000087 Page 4 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a ON OR AFTER cLass 1 01 2012 2 01 2012 10 01 2011 12 01 2011 5 30 2011 6 01 2011 3 22 2011 3 23 2011 10 23 2010 11 25 2010 9 01 2010 9 13 2010 8 09 2010 8 16 2010 7 17 2010 7 20 2010 8 21 2012 9 01 2012 2 21 2000 4 01 2004 12 12 2007 12 13 2007 8 23 2007 8 24 2007 7 10 2007 7 24 2007 6 20 2007 6 21 2007 1 03 2007 2 01 2007 10 11 2006 10 12 2006 9 13 2006 9 14 2006 7 26 2006 7 27 2006 11 10 2004 11 18 2004 10 28 2004 10 30 2004 4 11 2004 4 13 2004 1 02 2011 4 01 2015 11 10 2010 12 31 2010 8 16 2010 10 30 2010 7 03 2010 7 27 2010 3 12 2010 5 29 2010 12 25 2009 2 22 2010 11 04 2009 12 01 2009 10 11 2009 10 13 2009 11 01 2008 11 02 2008 7 10 2008 8 01 2008 16 2008 6 25 2008 4 21 2008 4 30 2008 3 03 2008 4 02 2008 2 08 2008 2 11 2008 12 20 2007 12 22 2007 DRPOSIT PREMIUM Employed Specialist RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. RILEY MEGAN E. ROMNEY LORENZO RYAN TIMOTHY J. DO SIMON GLENN W. DO STMON GLENN W. DO SIMON GLENN W. DO SIHON GLENN W. DO SIMON GLENN W. DO STMON GLENN W. DO SIMON GLENN W. DO SIMON GLENN W. DO SIMON GLENN W. DO SIMON GLENN W. DO SIHON GLENN W. DO STMONS CRAIG G. DO SIMONS CRAIG G. DO SINONS CRAIG G. DO STHONS CRAIG G. DO SIHONS CRAIG G. DO SIMONS CRAIG G. DO STMONS CRAIG G. DO SIMONS CRAIG G. DO STHONS CRAIG G. DO STUONS CRAIG G. DO SIKONS CRAIG G. DO SIMONS CRAIG G. DO STMONS CRAIG G. DO SIMONS CRAIG G. DO SINONS CRAIG G. DO 888888888 Form HPL 3 510 Policy 1000087 rage 5 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a Medical Injury which occurred RATE ON OR AFTER ANDBEFORE CLASS CLASS 10 18 2007 10 20 2007 5 01 2012 6 30 2012 1 01 2012 2 01 2012 11 01 2011 12 01 2011 4 01 2011 9 01 2011 3 06 2011 3 07 2011 1 27 2011 1 29 2011 12 28 2010 12 30 2010 11 09 2010 11 28 2010 10 12 2010 10 28 2010 8 01 2010 8 12 2010 7 13 2010 7 15 2010 6 26 2010 6 27 2010 5 07 2010 5 09 2010 4 18 2010 4 20 2010 3 27 2010 3 29 2010 2 26 2010 2 28 2010 1 08 2010 1 25 2010 12 13 2009 12 14 2009 11 27 2009 11 29 2009 10 26 2009 10 28 2009 2 21 2009 2 23 2009 1 01 2009 2 08 2009 11 27 2008 11 29 2008 10 04 2008 10 06 2008 9 21 2008 9 22 2008 8 07 2008 8 30 2008 7 07 2008 7 09 2008 5 04 2008 6 30 2008 4 09 2008 4 29 2008 4 09 2004 4 11 2004 7 10 2011 7 31 2011 12 01 2013 1 01 2014 8 01 2013 11 01 2013 2 01 2013 3 01 2013 12 21 2012 1 01 2013 DEPOSIT PREMIUM Employed Specialist SIMONS CRAIG G. DO SMITH SMITH SMITH SMITH SMITH SMITH SMITH SUITH SMITH SMITH SUITH SMITH SMITH SMITH SMITH SMITH SMITH SMITH SMITH SMITH BMITH SMITH SMITH SHITH SMITH SMITH SMITH SMITH SMITH SMITH RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. HD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD RICHARD L. MD ROBERT B. MD SPANGLER KENNETH DO SPORLEDER CHRISTOPHER BPORLEDER CHRISTOPHER SPORLEDER CHRISTOPHER SPORLEDER CHRISTOPHER 8888 Form HPL 3 510 Policy 1000087 Page 6 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE RXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a Medical Injury which occurred RATE ON OR AFTER AND BRFORE CLASS crLass 7 15 2010 7 16 2010 4 25 2010 4 28 2010 4 23 2009 4 24 2009 8 05 2008 8 06 2008 6 06 2006 6 08 2006 6 01 2012 8 01 2012 1 01 2012 3 01 2012 9 01 2011 12 01 2011 5 01 2011 8 01 2011 3 04 2011 3 05 2011 1 10 2011 2 01 2011 12 26 2010 12 27 2010 9 11 2010 11 07 2010 8 02 2010 8 12 2010 7 08 2010 7 22 2010 5 10 2010 6 22 2010 4 07 2010 4 27 2010 3 18 2010 3 20 2010 2 13 2010 2 15 2010 1 09 2010 1 26 2010 12 03 2009 12 30 2009 11 21 2009 11 23 2009 10 07 2009 10 26 2009 9 06 2009 9 26 2009 7 10 2009 8 29 2009 5 09 2009 24 2009 4 14 2009 4 26 2009 4 03 2009 4 04 2009 3 09 2009 3 23 2009 1 08 2009 2 24 2009 12 08 2008 12 26 2008 10 17 2008 11 24 2008 9 17 2008 9 25 2008 7 02 2008 9 08 2008 5 02 2008 6 22 2008 3 13 2008 4 25 2008 DRPOSTT PREMIUM Employed Specialist THOMPSON THOMPSON THOMPSON THOMPSON THOMPSON SHART MD SHARL MD SHART MD SHARI MD SHARI MD TURNER MICHAEL O. TURNER MICHAEL 0. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL 0. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHARL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL 0. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHABL 0. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. TURNER MICHAEL O. Form HPL 3 510 Policy 1000087 Page 7 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE This insurance applies only to a Medical Tnjury which occurred RATE ON OR AFTER AND BEFORE CIASS crass 2 22 2008 2 27 2008 2 04 2008 2 05 2008 1 24 2009 1 26 2009 4 22 2008 4 25 2008 3 11 2008 3 22 2008 8 29 2006 9 11 2006 3 03 2006 3 05 2006 6 11 2005 6 13 2005 3 31 2005 4 03 2005 3 18 2005 3 22 2005 1 13 2005 1 15 2005 12 06 2004 12 08 2004 10 16 2004 11 15 2004 8 15 2004 8 26 2004 6 07 2006 6 19 2006 4 15 2006 4 17 2006 2 11 2013 5 27 2013 9 24 2010 9 27 2010 12 09 2011 1 01 2012 11 01 2003 4 01 2005 DEPOSIT PREMIUM Medical Injury w Employed Specialist ON OR AFTER TURNER MICHAEL O. MD 2 22 2008 TURNER MICHAEL 0. MD 2 04 2008 TURNER ROBERT N. MD 1 24 2009 TURNER ROBERT N. MD 4 222008 TURNER ROBERT N. MD 3 11 2008 VONN SOMSAK MD 8 29 2006 VONN SOMSAK MD 3 03 2006 VONN SOMSAK MD 6 11 2005 VONN SOMSAK MD 3 31 2005 VONN SOMSAK MD 3 18 2005 VONN SOMSAK MD 1 13 2005 VONN SOMSAK MD 12 06 2004 VONN SOMSAK MD 10 16 2004 VONN SOMSAK MD 8 15 2004 WALTER BAUMSTARK LAUREL MD 6 07 2006 WALTER BAUMSTARK LAUREL MD 4 15 2006 WALTER GAIL E. MD 2 11 2013 WETZEL WILLIAM C. DO 9 24 2010 WINSTON THOMAS MD 12 09 2011 ZAFAR MOHAMMAD N. MD 11 01 2003 Hospitalist Minor Surgery DIEHL JEFFERY C. MD 9 16 2008 DIEHL JEFFERY C. MD 8 18 2008 DIEHL JEFFERY C. HD 6 09 2008 DIEHL JBFFERY C. MD 5 12 2008 EL DIRANI SAMER M TAISSIR MD 9 07 2009 EL DIRANI SAMER M TAISSIR MD 8 10 2009 EL DIRANI SAMER M TAISSIR MD 6 01 2007 GUPTA DEVINDER P. MD 5 01 2008 HADDADIN SHADI MD 3 07 2008 HALSEY KEVIN DALE MD 6 01 2007 HAUG DARIN L. DO 5 04 2008 HAUG DARIN L. DO 6 01 2007 KATUKOORI SHASHI MD 7 01 2011 7 25 2008 KEUHN DAVID J. MD INe nan nan nan nan 80222.0 5 31 2010 8 24 2008 6 12 2008 5 20 2008 9 14 2009 8 18 2009 7 20 2009 7 22 2013 9 16 2008 6 14 2008 5 05 2008 2 09 2008 7 28 2014 7 27 2008 Form HPL 3 510 Policy 1000087 Page 8 | 2 |
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EXTENDED REPORTING PERIOD COVERAGE EXTENSION OF INSURANCE TO EMPLOYED SPECIALIST This Schedule forms a part of this endorsement. SCHEDULE Employed Specialist KEUHN DAVID J. KEUHN DAVID dJ. KEUHN DAVID J. KEUHN DAVID J. XEUHN DAVID J. RIPPEY PETER C. MD RIPPEY PETER C. MD RIPPEY PETER C. MD SCHEURICH DANIEL REGAN MD SEGAL RADU ADRIAN MD STMONS CRAIG G. DO SIMONS CRAIG G. DO SIMONS CRAIG G. DO THOMPSON THOMPSON THOMPSON THOMPSON THOMPSON THOMPSON SHARI SHART SHART SHARI SHART SHART D MD 1D MD MD MD D MD HD 8D MD This insurance applies only to a Family or General Practice No Surgery ROMNEY LORENZO DO ROMNEY LORENZO DO Urgent Care ELFRINK MELANIE MD RIPPEY PETER C. MD Medical Tnjury which occurred RATR ON OR AFTRR AND BEFORE cLASs cLasg 6 28 2008 6 30 2008 5 31 2008 6 02 2008 3 22 2008 3 25 2008 1 18 2008 2 26 2008 12 08 2007 12 25 2007 5 01 2014 6 01 2014 2 01 2014 3 01 2014 11 07 2013 12 01 2013 6 23 2008 6 28 2008 7 01 2007 5 01 2008 7 18 2013 8 01 2013 2 01 2013 3 01 2013 10 05 2009 6 30 2011 6 04 2010 6 05 2010 3 18 2010 3 22 2010 1 17 2009 1 19 2009 9 10 2008 10 01 2008 8 01 2008 8 05 2008 7 01 2008 7 08 2008 80420 1 12 01 2009 4 01 2010 11 14 2008 11 01 2009 80424 1 11 04 2013 2 01 2014 6 01 2014 12 15 2014 DEPOSIT PREMIUM 1INC nan nan nan nan 80420.0 e nan nan nan nan 80424.0 Form HPL 3 510 Policy 1000087 Page 9 End of Endorsement | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No This attaching clause is completed only when this endorsement is issued afier policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MISSOURI MUTUAL AID AGREEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM Hospitals who are members of Missouri Hospital Plan MHP or policyholders of Medical Liability Alliance MLA at the time of a medical disaster who purchase hospital professional andor commercial general liability insurance from MHP or MLA and who have entered into a Mutual Aid Agreement MAA with other signatory hospitals are hereby covered in the event of a medical disaster subject to the following conditions. A medical disaster is defined as a critical incident that exceeds the effective response capability of an individual hospital. For purposes of this extension of coverage covered MAA agreements will be those on file with the Missouri Hospital Association MHA. Agreements other than those on file with MHA must be submitted to and approved by MHP or MLA. MHP Member MLA Policyholder to MHP Member MLA Policyholder Coverage If a Receiving Hospital and a Lending Hospital are both members of Missouri Hospital Plan or policyholders of Medical Liability Alliance and Participating Hospital as defined by the MAA insurance coverage will be extended to the Lending Hospital and its employees agents or those otherwise insured under its policy with MHP as an additional insured under Section II WHO IS AN INSURED of the Receiving Hospital s policy with MHP subject to all Conditions Exclusions Policy Limits Deductibles Endorsements and contract provisions applicable to the Receiving Hospital in the then effective insurance agreement between the Receiving Hospital and MHP Coverage shall also comply with the General Provisions of Section XI. Paragraph C. Liability for Transferred Personnel Patients Equipment and Supplies of the MAA. In the event that the policy limits of a Receiving Hospital which are to be considered primaty over any other limits are less than those of the Lending Hospital those of the Receiving Hospital must first be exhausted before the limits of the Lending Hospital may be called upon to respond and then such response will only take place at the written request to MHP by the Lending Hospital. Irrespective of the limits of coverage if said Lending Hospital does not inform MHP in writing that it desites its coverage to apply to a particular claim or claims on an excess basis MHP shall not be called upon to pay any claims losses settlements damages Form GEN 3 696 1 R01 13 Page 1 of 2 | 2 |
judgments legal expenses or any other costs in excess of the limits of liability provided to the Receiving Hospital under its insurance coverage with MHP or any self insurance arrangement. MHP Member MLA Policyholder to Non MHP Member Non MEA Policyholder Coverage If a Receiving Hospital is a member of MHP or policyholder of MLA and Lending Hospital is not a member of MHP or policyholder of MLA but is a Participating Hospital as defined by the MAA insurance coverage will be extended to the Lending Hospital and its employees agents or those otherwise insured under its hospital professional andor commercial general liability policy or self insurance as an additional insured under Section II WHO IS AN INSURED of the Receiving Hospital s policy with MHP subject to all Conditions Exclusions Policy Limits Deductibles Endorsements and contract provisions applicable to the Receiving Hospital in the then effective insurance agreement between the Receiving Hospital and MHP. Coverage shall also comply with the General Provisions of Section X1. Paragtaph C. Liability for Tt vansferred Personnel Patients Equipment and Supplies of the MAA If the Lending Hospital is a member of MHP and has policy limits greater than those of the Non Member Receiving Hospital the MHP coverage issued to the Lending Hospital shall be considered excess coverage and the signatory hospitals agree that MHP shall not be liable for the payment of any claims losses settlements damages judgments legal expenses or any other costs until and uniess the policy limits of the Receiving Hospital which shall be considered primary are exhausted. The Receiving Hospital must maintain insured or self insured limits of no less than 1 million per occurrence and 3 million in the aggregate. In the event that the policy limits of the Non member Receiving Hospital ate less than those of the MHP member Lending Hospital those of the Receiving Hospital must first be exhausted before the limits of the Lending Hospital may be called upon to respond and then such response will only take place at the written request to MHP by the Lending Hospital. Trrespective of the limits of coverage if said Lending Hospital does not inform MHP in writing that it desires its coverage to apply to a particular claim or claims on an excess basis MHP shall not be called upon to pay any claims losses settlements damages judgments legal expenses or any other costs in excess of the limits of liability provided to the Receiving Hospital. This extension of coverage is made at no cost to Receiving andor Lending Hospitals who are members of MHP or policyholders of MLA at the time of the relevant medical disaster. Form GEN 3 696 1 R01 13 Page2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 6 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM In consideration of an additional premium of 350 coverage provided by this policy is extended to include Host Liquor Liability for events to be held throughout the policy period by the Named Insured. Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 7 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Fitzgibbon Health Services Inc owner of nursing home but only with respect to liability arising out of your operations or premises owned by or rented to you It is further agreed that the inclusion of the Additional Insured shall not increase the Company s limit of liability as shown in the policy. If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section II Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury property damage or personal and advertising injury caused in whole or in part by your acts or omissions of those acting on your behalf 1. Tn the performance of your ongoing operations or 2. Tn connection with your premises owned by or rented to you. Page 1 of2 Contains Material Copyrighted by ISO Form GEN 3 519 2 R04 13 | 2 |
However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds the following is added to Section ITI Limits Of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by 1O Form GEN 3 519 2 R04 13 Page 2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 8 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Fitzgibbon Home Health Fitzgibbon Hospital Physical Therapy are provided coverage under policy If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section I Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury property damage or personal and advertising injury caused in whole or in part by your acts or omissions of those acting on your behalf 1. In the performance of your ongoing operations or 2. In connection with your premises owned by or rented to you. Contains Material Copyrighted by 1SO Form GEN 3 519 2 R04 13 Page 1 of2 | 2 |
However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.. With respect to the insurance afforded to these additional insureds the following is added to Section III Limits Of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by ISO Form GEN 3 519 2 R04 13 Page 2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 9 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED LESSOR OF LEASED EQUIPMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations ATL Financial Services a division of Phillips Medical Financial Services Inc andor its Assigns 22100 Bothell Everett Highway PO Box 3003 Bothell WA 98041 only with respect to leased equipment 1 one HDX 5000 Ulirasound System S N 00WZZ6 and 1 one HDI 3500 Ultrasound System S N 01NY7P If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section IT Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury property damage or personal and advertising injury caused in whole or in part by your maintenance operation or use of equipment leased to you by such persons or organizations. However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and Page of2 Contains Material Copyrighted by 1O Form GEN 3 520 2 R4 13 | 2 |
2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds this insurance does not apply to any occurrence which takes place after the equipment lease expires. C. With respect to the insurance afforded to these additional insureds the following is added to Section IIX Limits of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by 1O Form GEN 3 520 2 Rd13 Page2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 10 This attaching clause is completed only when this endorsement is issued afler policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED LESSOR OF LEASED EQUIPMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Citicorp Leasing Inc. andor its Assigns 450 Mamaroneck Avenue Harrison New York 10528 with respect to leased equipment Toshiba XVision EX CT Scanner Contract 37302 If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section II Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Sehedule but only with respect to liability for bodily injury property damage or personal and advertising injury caused in whole or in part by your maintenance operation or use of equipment leased to you by such persons or organizations. However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Contains Material Copyrighted by ISO Page 1 of 2 Form GEN 3 520 2 R4 13 | 2 |
B. With respect to the insurance afforded to these additional insureds this insurance does not apply to any occurrence which takes place after the equipment lease expires. C. With respect to the insurance afforded to these additional insureds the following is added to Section ITY Limits of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by SO Form GEN 3 520 2 R4 13 Page2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 11 This altaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED LESSOR OF LEASED EQUIPMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Siemens Financial Services Inc. 51 Valley Stream Parkway Mail Stop K21 Malvern PA 19355 but only with respect to leased equipment 1 MAGNETOM Espree as referenced in SMS Quote 1 60818A Contract 12635 and 1.5 T Avanto Espree Knee Foot Coil as referenced in Invivo Quote CQ021287 1 Contract 13251. If no entry appears above information requited to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section II Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury property damage or personal and advertising injury caused in whole or in part by your maintenance operation or use of equipment leased to you by such persons or organizations. However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and Page 1 of2 Contains Material Copyrighted by ISO Form GEN 3 520 2 R4 13 | 2 |
2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. C. With respect to the insurance afforded to these additional insureds this insurance does not apply to any occurrence which takes place afier the equipment lease expires. With respect to the insurance afforded to these additional insureds the following is added to Section INI Limits of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by ISO Form GEN 3 520 2 R4 13 Page2 of2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 12 ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY. ADDITIONAL INSURED MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE 1. Designation of Premises Part Leased to You 815 E. Broadway Brunswick MO 2. Name of Persons or Organizations Additional Insured Chariton County Community Foundation PO Box 14 Keytesville MO 65261 3. Additional Premium Inc If no entry appears above the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section I Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability arising out of the ownership maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions This insurance does not apply to 1. Any occurrence which takes place after you cease to be a tenant in that premises. 2. Structural alterations new construction or demolition operations performed by or on behalf of the persons or organizations shown in the Schedule. nan nan nan nan 1.0 nan nan nan nan 2.0 Page 1 0f2 Contains Material Copyrighted by ISO Form HGL 3 524 1 R04 13 | 2 |
However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.. With respect to the insurance afforded to these additional insureds the followingis added to Section III Limits Of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Tnsurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by ISO Form HGL 3 524 1 R04 13 Page 2 of 2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 13 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Fitzgibbon Health Services Inc. owner of nursing home but only with respeet to liability arising out of your operations or premises owned by or rented to you. Itis further agreed that the inclusion of the Additional Insured shall not increase the Company s limit of liability as shown in the policy. If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section II Who Ts An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury or professional injury caused in whole or in part by your acts or omissions of those acting on your behalf in the providing or failing to provide health care services or facilities. However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by contract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Contains Material Copyrighted by IO Page 1 0f2 Form HPL 3 544 1 R04 13 Page 1 0f2 | 2 |
B. With respect to the insurance afforded to these additional insureds the following is added to Section I Limits Of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Capyrighted by ISO Form HPL 3 544 1 R0O4 13 Page2 of2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 14 ENDORSEMENT EFFECTIVE POLICY NUMBER NAMED INSURED Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Persons or Organizations Fitzgibbon Home Health Fitzgibbon Hospital Physical Therapy are provided coverage under policy If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. Section II Who Is An Insured is amended to include as an additional insured the persons or organizations shown in the Schedule but only with respect to liability for bodily injury or professional injury caused in whole or in part by your acts or omissions of those acting on your behalf in the providing or failing to provide health care services or facilities. However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. If coverage provided to the additional insured is required by confract or agreement the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Page 1 of2 Contains Material Copyrighted by 1SO Form HPL 3 544 1 R04 13 | 2 |
B. With respect to the insurance afforded to these additional insureds the following is added to Section IIT Limits Of Insurance If coverage provided to the additional insured is required by a contract or agreement the most we will pay on behalf of the additional insured is the amount of insurance 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Contains Material Copyrighted by 1SO Form HPL 3 544 1 R04 13 Page2of2 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 15 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE 08 01 2015 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital m Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 2503 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE 2 TIVE EXPIRATION RETROACTIVE RATE DEPOSIT Employed Specialist DATE DATE DATE. CLASS CLASS PREMIUM Certified Registered Nurse Anesthetist W O Supervision Brown Brian CRNA 08 01 2015 07 01 2016 11 25 2013 75043 5A 2503 Prorated Premium Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 16 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE 09 01 2015 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hosptial o NN POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hosptial N A S B U Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 2650 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE EFFECTIVE EXPIRATION RETROACTIVE RATE DEPOSIT Employed Specialist DATE DATE DATE CLASS CLASS PREMIUM Family or General Practice No Surgery Peecher Carrie DO 09 01 2015 07 01 2016 09 01 2015 80420 1 2650 Also in consideration of an additional premium of 1149 the Professional Liability Coverage Part Extension of Declarations is amended to include 2200 clinic visits at 2305A South 65 Highway Marshall MO effective September 1 2015. Prorated Premium Estimated number of clinic visits for the remainder of the policy period. Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 17 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE 10 23 2015 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital in A FULILY NUMDBERD HEG 1000067 15 01 NAMED INSURED Fitzgibbon Hospital 5 Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of a return premium of 548 active coverage as stated on Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is cancelled October 23 2015 for Mary Ann Coatney NP. Further in consideration of an additional premium of 1592 Endorsement No. 4 Extended Reporting Period Coverage for Extension of Insurance to Employed Specialist Schedule is amended to include the following This insurance applies only o a Medical Injury which occurred ONORAFTER AND BEFORE 08 01 2014 10 23 2015 DEPOSIT PREMIUM 1592 RATE CLASS 75015 1 Employed Specialist Nurse Practitioncr Coatney Mary Ann NP This Extended Reporting Period Coverage will terminate if we no longer insurc the first Named Insured for HOSPITAL PROFESSIONAL LIABILITY. Prorated Premium Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 18 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE 09 21 2015 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital A A NAMED INSURED Fitzgibbon Hospital Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 2121 the FTE for Brian Brown CRNA was changed from a S0toa 1.0 effective September 21 2015. Prorated Premium Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 19 This attaching clause is completed onfy when this endorsement is issued ater policy issuance. ENDORSEMENT EFFECTIVE 01 04 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital f W A POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital m WUA Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM Tnn consideration of an additional premium of 3269 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE EFFECTIVE EXPIRATION RETROACTIVE RATE DEPOSIT Employed Specialist DATE DATE DATE CLASS CLASS PREMIUM Surgery Orthopedic No Back Surgery White Richard MD 01 04 2016 07 01 2016 01 04 2016 80154 5 3108 Nurse Practitioner Lucas Carric NP 01 04 2016 07 01 2016 01 04 2016 75015 1 s 161 1 s 161 nan nan nan nan 75015.0 01 04 2016 01 04 2016 07 01 2016 Also in consideration of an additional premium of 450 the Professional Liability Coverage Part Extension of Declarations is amended to include 832 clinic visits at 2305 South 65 Highway Marshall MO effective January 4 2016. Minimum Premium Estimated number of clinic visits for the remainder of the policy period. Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 20 This attaching clause is completed only when this endorsement is issued after policy issuance. ENDORSEMENT EFFECTIVE 01 01 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM In consideration of a return premium of N A the Commercial General Liability Coverage Part Extension of Declarations is amended to delete the following 15 01 spital DO I. 17 1701 South Miami Suite 201 Marshall MO Retroactive Date 08 04 2008 Code Number of Deposit Classification Number Exposures Premium 7 Apartment Buildings 60010 1 Unit 38 Also in consideration of an additional premium of Waived the Commercial General Liability Coverage Part Extension of Declarations is amended to add the following 2265 South Liberty Road Marshall MO Retroactive Date 01 01 2016 Code Number of Deposit Classification o Number Exposures Premium Apartment Buildings 60010 1 Unit Waived Including Products andor Completed Operations Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 21 This attaching clause is completed only when this endorsentent is issued after policy issuance. ENDORSEMENT EFFECTIVE 01 11 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital OW m A i POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital Authorized Represftative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM In consideration of an additional premium of Included the Commercial General Liability Coverage Part Extension of Declarations is amended to change the following 3 2301 South 65 Highway Marshall MO Retroactive Date 07 01 2003 o Code Numberof Deposit Classification Number Exposures Premium 3 Vacant Buildings Not Factories 68607 4150 Sq. Tt. Included Also in consideration of an additional premium of Waived the Commercial General Liability Coverage Part Extension of Declarations is amended to add the following 2301 South 65 Highway Suite 2 Marshall MO Retroactive Date 07 01 2003 16 Code Number of Deposit Classification Number Exposures Premium 16 Buildings or Premises Bank or Office 61218 1850 Sq. Ft. Waived Mercantile or Manufacturing Maintained by The Insured Lessor s Risk Only Including Products andor Completed Operations Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Enmsement No 22 This attaching clause is completed only when this endorsement is issued after policy issuance ENDORSEMENT EFFECTIVE 01 26 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital m Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 3108 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE EFFECTIVE EXPIRATION RETROACTIVE RATE DEPOSIT Employed Speci DATE DATE DATE CLASS CLASS PREMIUM gery Orthopedic No Back Surgery Pickett Clinton DO 01 26 2016 07 01 2016 01 26 2016 80154 5 3108 Also in consideration of an additional premium of 350 the Professional Liability Coverage Part Extension of Declarations is amended to include 690 clinic visits at 2305A South 65 Highway Marshall MO effective January 26 2016. Minimum Premium Rstimated number of c visits for the remainder of the policy period Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN hndwsementN 23 This attaching clause is completed only when his endorsement is ssucd after policy issuance. ENDORSEMENT EFFECTIVE 02 01 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital m AQO t 1 N POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital E m M Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 5113 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE EFFECTIVE EXPIRATION RETROACTIVE RATE DEPOSIT Employed Specialist DATE DATE DATE CLASS CLASS PREMIUM Surgery General Gault Jason DO 02 01 2016 07 01 2016 02 01 2016 80143 5 513 Also in consideration of an additional premium of 200 the Professional Liability Coverage Part Extension of Declarations is amended to include 396 clinic visits at 2305 South 65 Highway Marshall MO effective February 1 2016. Prorated Premium Estimated number of clinie visits for the remainder of the policy perlod. Form GEN 3 100 | 2 |
MISSOURI HOSPITAL PLAN Endorsement No 24 This attaching clause is completed only when this endorscment is issucd after policy issuance ENDORSEMENT EFFECTIVE 01 01 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital q m N. POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital Authorizadfcpresenm ve THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CEINEFRAT CHANOCTIT NNDORSEMINNT GENERAL CHANGE ENDORSEM This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of a return premium of 2402 active coverage as stated on Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is cancelled January 1 2016 for Kerrin Papreck MD. Further in consideration of an additional premium of 9671 Endorsement No. 4 Extended Reporting Period Coverage for Extension of Insurance to Employed Specialist Schedule is amended to include the following This insurance applies only toa Medical Injury which occurred Employed Specialist OR AFT AND BEFORE amily or Papreck Kei 11 22 2010 01 01 2016 DEPOSIT PREMIUM 9671 This Extended Reporting Period Coverage will terminate if we no longer insure the first Named Insured for HOSPITAL PROFESSIONAL LIABILITY. Prorated Premium Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 25 This attaching clause is completed only when this endorsement s issued after policy issuance. ENDORSEMENT EFFECTIVE 03 21 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital m NAMED INSURED Fitzgibbon Hospital Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 827 the FTE for Clinton Pickett DO was changed from a.25 to a 1.0 effective March 21 2016. Prorated Premium Form GEN 3 100 | 2 |
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MISSOURI HOSPITAL PLAN Endorsement No 26 This attaching clause is completed only wher this endorsement is issued afler policy issuance. ENDORSEMENT EFFECTIVE 05 09 2016 POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital POLICY NUMBER HPG 1000087 15 01 NAMED INSURED Fitzgibbon Hospital Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following HOSPITAL PROFESSIONAL LIABILITY COVERAGE FORM In consideration of an additional premium of 161 the Hospital Professional Liability Coverage Form Endorsement No. 3 Extension of Insurance to Employed Specialist Schedule is amended to include the following COVERAGE COVERAGE EFFECTIVE EXPIRATION RETROACTIVE RATE DEPOSIT DATE DATE DATE CLASS. CLASS PREMIUM 05 09 2016 07 01 2016 05 09 2016 75015 1 s 161 nployed Specialist Nurse Practitioner Ferri Alyssa CNS Minimum Premiun Form GEN 3 100 | 2 |
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Missouri Hospital Plan 4700 Country Club Drive P. O Box 1498 Jefferson City Missouri 65102 1498 573 893 5300 Member HEALTHCARE SERVICES GROUP SERVING MISSOURI HOSPITALS THIS POLICY JACKET WITH THE DECLARATIONS PAGE AND FORMS AND ENDORSEMENTS IF ANY ISSUED TO FORM A PART THEREOF COMPLETES THIS POLICY Form GEN 2 165 1 R01 15 | 2 |
A THIS POLICY CONSIS I S OF declarations common policy conditions one simore coverage parts. A coverage part consists ot one or more coverage forms and applicable forms and endorsements. COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions CANCELLATION 1. The first Named Insured shown in the Declarations may cancel this policy by mailing or delivering to us advance written notice of cancellation. 2. We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation stating the actual reason for cancellation at least a. 10 days before the effective date of cancellation if we cancel for nonpayment of premium b. 30 days before the effective date of cancellation if cancellation is for one or more of the following reasons 1 Fraud or material misrepresentation affecting this policy or a claim filed under this policy or a violation of any of the terms or conditions of this policy Changes in conditions after the effective date of this policy which have materially increased the risk assumed 3 We become insolvent or 4 We involuntarily lose reinsurance for this policy 60 days before the effective date of cancellation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured s last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5. If this policy is cancelled we will send the first Named Insured any premium refund due. If we cancel the refund will be pro rata. If the first Named Tnsured cancels the refund may be less than pro rata. The cancellation will be effective even if we have notmade or offered a refund. 6. Ifnotice is mailed proof of mailing will be sufficient proof of notice. CHANGES This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent. This policy s terms can be amended or waived only by endorsement issued by us and made a part of this policy. EXAMINATION OF YOUR BOOKS AND RECORDS We may examine and audit your books and records as they relate to this policy at any time during the policy period and up to three years afterward. D. E. INSPECTIONS AND SURVEYS 1. We have theright to a Make inspections and surveys at any time b. Give you reports on the conditions we find and Recommend changes. 2. We are not obligated to make any inspections surveys reports or recommendations and any such actions we do undertake relate only to insurability and the premiums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions a. Are safe or healthful or b. Comply with laws regulations codes or standards.. Paragraphs 1. and 2. of this condition apply not only to us but also to any rating advisory rate service or similar organization which makes insurance inspections surveys reports or recommendations. Paragraph 2. of this condition does not apply to any inspections surveys reports or recommendations we may make relative to certification under state or municipal statutes ordinances or regulations of boilers pressure vessels or elevators. NONRENEWAL 1. We may elect not to renew this policy by mailing or delivering to the first Named Insured at the last mailing address known to us written notice of nonrenewal stating the actual reason for nonrenewal at least sixty days prior to the effective date of the nonrenewal. 2. Ifnotice is mailed proof of mailing will be sufficient proof of notice. PREMIUMS The first Named Insured shown in the Declarations 1. Isresponsible for the payment of all premiums and 2. Will be the payee for any return premiums we pay. TRANSFER OF YOUR RIGHTS AND DUTIES UNDER THIS POLICY Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named insured. If you dic your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal representative is appointed anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. Policy Jacket Page 2 Form GEN 2 165 1 RO1 15 | 2 |
1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT Broad Form The insurance does not apply A B. Under any Liability Coverage to bodily injury or property damage 1 With respect to which an insured under the policy is also an insured under a nuclear energy liability policy issued by Nuclear Energy Liability Insurance Association Mutual Atomic Energy Liability Underwriters Nuclear Insurance Association of Canada or any of their successors or would be an insured under any such policy but for its termination upon exhaustion of its limit of liability or Resulting from the hazardous properties of nuclear material and with respect to which a any person or organization is required to maintain financial protection pursuant to the Atomic Energy Act of 1954 or any law amendatory thereof or b the insured is or had this policy not been issued would be entitled to indemnity from the United States of America or any agency thereof under any agreement entered into by the United States of America or any agency thereof with any person or organization. Under any Medical Payments coverage to expenses incurred with respect to bodily injury resulting from the hazardous properties of nuclear material and arising out of the operation of a nuclear facility by any person or organization. Under any Liability Coverage to bodily injury or property damage resulting from hazardous properties of nuclear material if 1 The nuclear material a is at any nuclear facility owned by or operated by or on behalf of an insured or b has been discharged or dispersed therefrom The nuclear material is contained in spent fuel or waste at any time possessed handled used processed stored transported or disposed of by or on behalf of an insured or The bodily injury or property damage arises out of the furnishing by an insured of services materials parts or equipment in connection with the planning construction maintenance operation or use of any nuclear facility but if such fac is located within the United States of America its territories or possessions or Canada this exclusion 3 applies only to property damage to such nuclear facility and any property thereat. 2 3 2. As used in this endorsement Hazardous properties include radioactive toxic or explosive properties. Nuclear material means source material special nuclear material or by product material. Source material special nuclear material and by product material have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof. Spent fuel means any fuel clement or fuel component solid or liquid which has been used or exposed to radiation in a nuclear reactor. Waste means any wastc malerial a containing by product material other than the tailings or wastes produced by the extraction or concentration of uranium or thorium from any ore processed primarily for its source material content and b resulting from the operation by any person or organization of any nuclear facility included under the first two paragraphs of the definition of nuclear facility. Nuclear facility means Any nuclear reactor Any cquipment or device designed or used for Iseparating the isotopes of uranium or plutonium 2 processing or utilizing spent fuel or 3 handling processing or packaging wastc Any cquipment or device used for the processing fabricating or alloying of special nuclear material if at any time the total amount of such material in the custody of the insured at the premises where such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 or any combination thercof o more than 250 grams of uranium 235 Any structure basin excavation premises or place prepared or used for the storage or disposal of waste and includes the site on which any of the foregoing is located all operations conducted on such site and all premises used for such operations. Nuclear reactor means any apparatus designed or used to sustain nuclear fission in a self supporting chain reaction or to contain a critical mass of fissionable material. Property damage includes all forms of radioactive contamination of property. Policy Jacket Page 3 TForm GEN 2 165 1 RO15 | 2 |
ASBESTOS EXCLUSION This insurance does not apply to 1 Bodily injury property damage or personal and advertising injury arising out of resulting from caused or contributed to by asbestos or exposure to asbestos or 2 The costs of abatement mitigation removal or disposal of asbestos or 3 Any supervision instructions warnings or advice given or which should have been given in connection with the above and 4 Any obligation to share damages with or repay someone else who must pay damages because of such injury or damage. SERVICES FURNISHED BY HEALTH CARE PROVIDERS EXCLUSION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM. The fotlowing exclusion is added to Paragraph 2. Excluslons of Section I Coverage A Bodily Injury And Property Damage Liability and Paragraph 2. Exclusions of Section I Coverage B Personal and Advertising Injury Liability This insurance does not apply to bodily injury property damage or personal and advertising injury arising out of 1. The rendering or failure to render A Medical surgical dental x ray or nursing services treatment advice or instruction or the related furnishing of food or beverages b. Any health or therapeutic service treatment advice or instruction or Any service treatment advice or instruction for the purpose of appearance or skin enhancement hair removal or replacement or personal grooming. The furnishing or dispensing of drugs or medical dental or surgical supplies or appliances The handling or treatment of dead bodies including autopsics organ donation or other procedures or. Participating in or subject to credentialing activities. awp MEDICAL PAYMENTS COVERAGE PATIENT EXCLUSION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following exclusions are added to paragraph 2. Exclusions of Coverage C Medical Payments Section 1 Coverages We will not pay expenses for 1. Bodily injury to any patient who is being treated or cared for. 2. Medical services rendered to anyone by you or your employees or any person or organization under contract with you to provide these medical services. ASSESSMENT PROVISION This policy is issued on an assessable basis. Assessments may be levied in accordance with Missouri Hospital Plan Bylaws which are included in this policy by reference. AMENDMENT OF DEFINITION Wherever used in this policy the term premium shall mean assessment and the term advance premium shall mean deposit assessment. IN WITNESS WHEREOF Missouri Hospital Plan has caused this Policy to be signed by its President and Scoretaty at its home office in Jefferson City Missouri. Wdm G VQMA Secretary Treasurer i President CEO Policy Jacket Page 4 Form GEN 2 165 1 R01 15 | 2 |
P N TRAVELERS Report Claims Immediately by Calling 1 800 832 7839 Speak directly with a claim professional 24 hours a day 365 days a year Unless Your Policy Requires Written Notice or Reporting COMMERCIAL INSURANCE A Custom Insurance Policy Prepared for KANSAS CITY SOUTHERN 427 W. 12TH STREET KANSAS CITY MO 64105 Presented by LOCKTON COMPANIES LLC P N TRAVELERS Report Claims Immediately by Calling 1 800 832 7839 Speak directly with a claim professional 24 hours a day 365 days a year Unless Your Policy Requires Written Notice or Reporting COMMERCIAL INSURANCE A Custom Insurance Policy Prepared for KANSAS CITY SOUTHERN 427 W. 12TH STREET KANSAS CITY MO 64105 Presented bv LOCKTON COMPANIES LLC P N TRAVELERS Report Claims Immediately by Calling 1 800 832 7839 Speak directly with a claim professional 24 hours a day 365 days a year Unless Your Policy Requires Written Notice or Reporting COMMERCIAL INSURANCE A Custom Insurance Policy Prepared for KANSAS CITY SOUTHERN 427 W. 12TH STREET KANSAS CITY MO 64105 Report Claims Immediately by Calling 1 800 832 7839 Speak directly with a claim professional 24 hours a day 365 days a year Unless Your Policy Requires Written Notice or Reporting COMMERCIAL INSURANCE A Custom Insurance Policy Prepared for KANSAS CITY SOUTHERN 427 W. 12TH STREET KANSAS CITY MO 64105 | 2 |
PN TRAVELERS One Tower Square Hartford Connecticut 06183 TRAVELERS CORP. TEL 1 800 328 2189 COMMON POLICY DECLARATIONS ISSUE DATE 082219 POLICY NUMBER TC2J GLSA415J5114 TIL19 INSURING COMPANY TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. NAMED INSURED AND MAILING ADDRESS KANSAS CITY SOUTHERN AS PER IL T3 40 427 W. 12TH STREET KANSAS CITY MO 64105 2. POLICY PERIOD From 080119 to 080120 1201 A.M. Standard Time at your mailing address. 3. LOCATIONS Premises Bldg. Loc. No. No. Occupancy Address ON FILE WITH COMPANY 4. COVERAGE PARTS FORMING PART OF THIS POLICY AND INSURING COMPANIES COMMERCIAL GENERAL LIABILITY COV PART DECLARATIONS CG TO 01 11 03 TIL EMPLOYEE BENEFITS LIABILITY COV PART DECLARATIONS CG TO 09 03 95 TIL. NUMBERS OF FORMS AND ENDORSEMENTS FORMING A PART OF THIS POLICY SEE IL T8 01 10 93 SUPPLEMENTAL POLICIES Each of the following is a separate policy containing its complete provisions Policy Policy No. Insuring Company SEE CALCULATION OF PREMIUM COMPOSITE RATES ENDORSEMENT AMS BINDER BILLED 248067 7. PREMIUM SUMMARY Provisional Premium Due at Inception Due at Each COUNTERSIGNED BY NAME AND ADDRESS OF AGENT OR BROKER LOCKTON COMPANIES LLC NA287 444 W 47TH STREET SUITE 900 KANSAS CITY MO 64112 Authorized Representative DATE IL TO 02 11 89REV. 09 07 OFFICE KANSAS CITY PAGE 1 OF 1 | 2 |
ISSUE DATE 08 22 19 POLICY NUMBER TC2J GLSA415J5114 TIL19 Dear Valued Policyholder We are excited to inform you about changes to the structure of your commercial general liability CGL insurance. We are implementing a new proprietary CGL Coverage Form that will update and further simplify our approach to that coverage. Our new CGL coverage form is more closely aligned with ISO s current CGL coverage form and it includes numerous provisions previously contained in our proprietary mandatom endorsements and several coverage enhancements that have been provided in our commonly used XTEND endorsements. In addition we have updated many of our CGL endorsements for improved readability and consistency across our portfolio of policy forms. To complement these CGL policy form changes we are also transitioning our Liquor Liability LL coverage to ISO s current LL coverage form modified by a proprietary Liquor Liability Amendatory Endorsement. This transition will improve consistency and coordination of CGL and LL coverages. Your new Travelers CGL policy will contain coverage terms and conditions substantially similar to those in your expiring Travelers CGL policy. Also in order to make this transition to our new proprietary policy forms as easy as possible for you we will adjust any claims for CGL coverage under your new policy based upon the terms and conditions of either your expiring policy or your new policy whichever are broader. Likewise if your expiring policy includes LL coverage and you are renewing that coverage with us we will adjust any claims for LL coverage under your new policy based upon the terms and conditions of either your expiring policy or your new policy whichever are broader. However this approach to adjustment of claims for CGL and LL coverage is subject to the following exceptions Any differences in the insured locations or insurance schedules or the identity of named insureds or additional insureds. Any reductions in coverage that have been requested by you or your agent or broker or to which you or your agent or broker have agreed during renewal negotiations or any exposures you have elected to insure elsewhere. Any reduction in the amount of the limits of insurance shown in any Declarations or endorsement for your new policy from the amount shown for substantially similar coverage in any Declarations or endorsement for your expiring policy. Any increase in the amount of any deductible self insured retention retrospective loss limitation or coinsurance obligation shown in any Declarations or endorsement for your new policy from the amount shown for substantially similar coverage in any Declarations or endorsement for your expiring policy or any change from a loss sensitive to guaranteed cost rating plan or vice versa. Any other exceptions shown below. We will apply this approach to claims adjusted under your first new Travelers policy. Any claim adjusted under a subsequent Travelers policy will be adjusted based only upon the terms and conditions of that policy. Please review your expiring and new Travelers policies carefully retain your expiring policy and contact your agent or broker if you have any questions about this letter. We appreciate your business and thank you for choosing to insure with us. PN U32004 19 Page 1of 2 2019 The Travelers Indemnity Company. Al rights reserved. | 2 |
PN U32004 19 Page 2 of 2 2019 The Travelers Indemnity Company. Al rights reserved. | 2 |
N TRAVELERS POLICY NUMBER TC2J GLSA415J5114 TIL19 EFFECTIVE DATE 08 01 19 ISSUE DATE 08 22 19 LISTING OF FORMS ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS. COMMON POLICY DECLARATIONS FORMS ENDORSEMENTS AND SCHEDULE NUMBERS LIBERALIZATION LETTER GL PRODUCT MODERN COMMON POLICY CONDITIONS CALCULATION OF PREMIUM COMPOSITE RATE S BROADENED NAMED INSURED ENDORSEMENT EARLIER NOT CANCEL NONRENEWAL PROV BY US COMMERCIAL GENERAL LIABILITY cG cG CcG cG GN GN GN CcG cG CcG cG cG CcG cG CcG cG cG CcG cG CcG GN CGT001 COMMERCIAL GENERAL LIAB COV DEC TABLE OF CONTENTS COM GEN LIAB COV COMMERCIAL GENERAL LIABILITY COV FORM WAIVER OF TRANSFER OF RIGHTS OF RECOVERY EXTENSION OF COVERAGE BODILY INJURY EMPLOYERS OVERHEAD LIABILITY AMEND OF COV INTERNATIONAL LTD FORM ADDITIONAL INSURED VENDORS BROAD FORM INCIDENTAL MEDICAL MALPRACTICE BLKT AI PERS ORGS BI PD REQ IN WRITING COV FOR BI CO EMPLOY OR OTHER VOLUNTEER AMEND NON CUMULATION OF EACH OCC AMEND CONTRAC LIAB EXCL EXC TO NAMED INS EXCL VIOLATION OF CONSUMER FIN PROT LAWS AMEND LIQ EXCL EXCEPT SCHED PREM ACTIV EXCLUSION INTERCOMPANY PRODUCTS SUITS EXCLUSION DISCRIMINATION EXC HAZARD CONNECTED DESIGNATED EXPOSURE MISSOURI CHGS DEFINITION OF POLLUTANTS AMEND DUTIES OCCUR OFF CLAIM SUIT COND EMPLOYERS OVERHEAD LIABILITY OHIO EMPLOYEE BENEFITS LIABILITY CG TO 09 03 95 CG TO 43 01 16 CG T1 01 01 16 CG F8 93 01 16 EMPLOYEE BENEFITS LIAB COV PART DEC EMPLOYEE BENEFITS LIAB TABLE OF CONTENTS EMPLOYEE BENEFITS LIABILITY COV FORM MISSOURI CHANGES EBL PAGE ILT8 011093 | 2 |
N TRAVELERS POLICY NUMBER TC2J GLSA415J5114 TIL19 EFFECTIVE DATE 08 01 19 ISSUE DATE 08 22 19 MULTIPLE SUBLINE ENDORSEMENTS C COMMERCIAL GENERAL LIABILITY EMPLOYEE BENEFITS LIABILITY LIQUOR LIABILITY CG D3 55 01 17 DEDUCTIBLE ENDORSEMENT C E L CG T3 33 11 03 LIMIT WHEN TWO OR MORE POLICIES APPLY C E L CG 26 25 04 05 MO CHANGES GUARANTY ASSOCIATION C L INTERLINE ENDORSEMENTS IL IL IL IL IL IL 01 15 03 11 03 15 01 15 09 08 02 13 FEDERAL TERRORISM RISK INS ACT DISCLOSE DESIGNATED ENTITY CANC PROVIDED BY US AMNDT COMMON POLICY COND PROHIBITED COVG CAP ON LOSSES CERTIFIED ACT OF TERRORISM NUCLEAR ENERGY LIAB EXCL END BROAD FORM MISSOURI CHGS CANCELLATION NONRENEWAL PAGE ILT8 011093 | 2 |
COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions A. Cancellation 1. The first Named Insured shown in the Decla rations may cancel this policy by mailing or delivering to us advance written notice of cancellation. 2. We may cancel this policy or any Coverage Part by mailing or delivering to the first Named Insured written notice of cancellation at least a. 10 days before the effective date of can cellation if we cancel for nonpayment of premium or b. 30 days before the effective date of can cellation if we cancel for any other rea son. 3. We will mail or deliver our notice to the first Named Insured s last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. If the policy is cancelled that date will become the end of the policy period. If a Coverage Part is cancelled that date will become the end of the policy period as respects that Coverage Part only. 5. If this policy or any Coverage Part is can celled we will send the first Named Insured any premium refund due. If we cancel the re fund will be pro rata. If the first Named In sured cancels the refund may be less than pro rata. The cancellation will be effective even if we have not made or offered a re fund. 6. If notice is mailed proof of mailing will be sufficient proof of notice. B. Changes This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declara tions is authorized to make changes in the terms of this policy with our consent. This policy s terms can be amended or waived only by endorsement issued by us as part of this policy. C. Examination Of Your Books And Records We may examine and audit your books and records as they relate to this policy at any time during the policy period and up to three years afterward.. Inspections And Surveys 1. We have the right to a. Make inspections and surveys at any time b. Give you reports on the conditions we find and. Recommend changes. 2. We are not obligated to make any inspec tions surveys reports or recommendations and any such actions we do undertake relate only to insurability and the premiums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions a. Are safe or healthful or b. Comply with laws regulations codes or standards. 3. Paragraphs 1. and 2. of this condition apply not only to us but also to any rating advi sory rate service or similar organization which makes insurance inspections surveys reports or recommendations. 4. Paragraph 2. of this condition does not apply to any inspections surveys reports or rec ommendations we may make relative to certi fication under state or municipal statutes or dinances or regulations of boilers pressure vessels or elevators. Premiums 1. The first Named Insured shown in the Decla rations a. Is responsible for the payment of all pre miums and b. Wil be the payee for any return premi ums we pay. 2. We compute all premiums for this policy in accordance with our rules rates rating plans premiums and minimum premiums. The pre mium shown in the Declarations was com puted based on rates and rules in effect at IL TO 01 01 07 Rev. 09 18 Includes the copyrighted material of Insurance Services Office Inc. with its permission. Page 1 of 2 | 2 |
the time the policy was issued. On each re newal continuation or anniversary of the ef fective date of this policy we will compute the premium in accordance with our rates and rules then in effect. F. Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named in sured. If you die your rights and duties will be trans ferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal representative is appointed anyone having proper temporary cus tody of your property will have your rights and duties but only with respect to that property. Equipment Breakdown Equivalent to Boiler and Machinery On the Common Policy Declarations the term Equipment Breakdown is understood to mean and include Boiler and Machinery and the term Boiler and Machinery is understood to mean and include Equipment Breakdown. This policy consists of the Common Policy Declarations and the Coverage Parts and endorsements listed in that declarations form. In return for payment of the premium we agree with the Named Insured to provide the insurance afforded by a Coverage Part forming part of this policy. That insurance will be provided by the company indicated as insuring company in the Common Policy Declarations by the abbreviation of its name opposite that Coverage Part. One of the companies listed below each a stock company has executed this policy and this policy is counter signed by the officers listed below The Travelers Indemnity Company IND The Phoenix Insurance Company PHX The Charter Oak Fire Insurance Company COF Travelers Property Casualty Company of America TIL The Travelers Indemnity Company of Connecticut TCT The Travelers Indemnity Company of America TIA Travelers Casualty Insurance Company of America ACJ President Wty C S Includes the copyrighted material of Insurance Services Office Inc. with its permission. IL. TO 01 01 07 Rev. 09 18 Page 2 of 2 | 2 |
POLICY NUMBER TC2J GLSA415J5114 TIL19 ISSUE DATE 08 22 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALCULATION OF PREMIUM COMPOSITE RATES A. SCHEDULE 1. This endorsement modifies insurance provided under the following Coverage Parts COMMERCIAL GENERAL LIABILITY EMPLOYEE BENEFITS LIABILITY. This endorsement applies to the Declarations from 08 01 19 o 08 01 20 Standard Time at your mailing address shown in the Common Policy Declarations.. Definition of Premium Base Bases Audited Sales Exceptions if any to compositing of premium calculation 1201 AM. 5. Premium Schedule COVERAGE 342 40050 PREMIUM BASE PER 1000 ESTIMATED EXPOSURE 10000000 ADVANCE PREMIUM 33500 RATE 3.35 If no entry appears above information required to complete this endorsement will be shown in te Declarations as applicable to this endorsement. premium shall be computed in accordance with the policy and this endorsement. If the earned premium thus computed exceeds the estimated advance premium paid you shall pay the ex cess to us if less we shall return to you the unearned paid portion. Rates and premiums for any subsequent Declarations Periods shall be determined at the inception date of those respective periods and shall be specified in en dorsements to be added to the policy. After termination of each period the earned premium shall be computed in accordance with the policy and this endorsement. B. PROVISIONS 1. Referring to the Schedule above the premium for the Coverage Parts shown in item 1 except with respect to any exceptions shown in item 4 shall be computed in accordance with the premium base bases and rate rates desig nated in item 5. 2. The premium for the excepted hazards shall be computed in accordance with the rates and rules filed by us or on our behalf. 3. The advance premium stated above is an es timated premium for the Declarations Period. Upon termination of this period the earned Page 1 of 1 IL T3 02 07 86 Rev. 12 08 | 2 |
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BROADENED NAMED INSURED ENDORSEMENT This endorsement modifies insurance provided under the following ALL COVERAGES INCLUDED IN THIS POLICY The following is added as a Named Insured in Item 1. of the Declarations Any of your subsidiaries other than a partnership or joint venture that is not shown as a Named Insured in the Declarations is a Named Insured if a. You are the sole owner of or maintain an ownership interest of more than 50 in such subsidiary on the first day of the policy period and b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for loss that occurred a. Before you maintained an ownership interest of more than 50 in such subsidiary or After the date if any during the policy period that you no longer maintain an ownership interest of more than 50 in such subsidiary. Each such subsidiary will be deemed to be designated in the Declarations as the type of organization indicated in its name or the documents that govern its structure. b. ILT3 4008 18 Page 1 of 1 2018 The Travelers Indemnity Company. Al rights reserved. | 2 |
POLICY NUMBER TC2J GLSA415J5114 TIL19 ISSUE DATE08 22 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EARLIER NOTICE OF CANCELLATION NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION Number of Days Notice 90 WHEN WE DO NOT RENEW Nonrenewal Number of days Notice 90 CANCELLATION WHEN WE DO NOT RENEW Nonrenewal PROVISIONS A. For any statutorily permitted reason other than nonpayment of premium the number of days re quired for notice of cancellation as provided in the CONDITIONS Section of this insurance or as amended by any applicable state cancellation endorsement applicable to this insurance is in creased to the number of days shown in the SCHEDULE above. B. For any statutorily permitted reason other than nonpayment of premium the number of days re quired for notice of When We Do Not Renew Nonrenewal as provided in the CONDITIONS Section of this insurance or as amended by any applicable state When We Do Not Renew Nonrenewal endorsement applicable to this in surance is increased to the number of days shown in the SCHEDULE above. IL T3 20 09 97 Copyright The Travelers Indemnity Company 1997 Page 1 of 1 | 2 |
GENERAL LIABILITY | 2 |
GENERAL LIABILITY | 2 |
A TRAVELERS.I One Tower Square Hartford Connecticut 06183 COMMERCIAL GENERAL LIABILITY POLICY NO. TC2J GLSA415J5114 TIL19 COVERAGE PART DECLARATIONS ISSUE DATE 08 22 19 INSURING COMPANY TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA DECLARATIONS PERIOD From 08 01 19 to 08 01 20 1201 A.M. Standard Time at your mailing address shown in the Common Policy Declarations. The Commercial General Liability Coverage Part consists of these Declarations and the Coverage Form shown below. 1. COVERAGE AND LIMITS OF INSURANCE COMMERCIAL GENERAL LIABILITY COVERAGE FORM LIMITS OF INSURANCE General Aggregate Limit Other than Products Completed Operations 2000000 Products Completed Operations Aggregate Limit 2000000 Personal Advertising Injury Limit 1000000 Each Occurrence Limit 1000000 Dmge To Premises Rented To You Limit any one premises 1000000 Medical Expense Limit any one person 5000 LIMITS OF INSURANCE 2000000 2000000 1000000 1000000 1000000 5000 W w o w0 n 2. AUDIT PERIOD ANNUAL 3. FORM OF BUSINESS CORPORATION 4. NUMBERS OF FORMS SCHEDULES AND ENDORSEMENTS FORMING PART OF THIS COVERAGE PART ARE ATTACHED AS A SEPARATE LISTING. COMMERCIAL GENERAL LIABILITY COVERAGE IS SUBJECT TO A GENERAL AGGREGATE LIMIT CGT0011103 Order CG A0 131103 PRODUCER LOCKTON COMPANIES LLC Page 1 of 1 095 NA287 OFFICE KANSAS CITY | 2 |
TABLE OF CONTENTS COMMERCIAL GENERAL LIABILITY COVERAGE FORM CGT1000219 SECTION COVERAGES Beginning on Page Coverage A Bodily Injury and Property Insuring Agreement Damage Liability Exclusions........... Coverage B Personal and Advertising Insuring Agreement. Injury Liability Exclusions........... Coverage C Medical Payments Insuring Agreement Exclusions........... Supplementary Payments SECTION Il WHO IS AN INSURED SECTION lll LIMITS OF INSURANCE SECTION IV COMMERCIAL GENERAL LIABILITY CONDITIONS Bankruptcy Duties In The Event Of Occurrence Offense Claim Or Suit. Legal Action Against Us. Other Insurance. Premium Audit Representations Separation Of Insureds Transfer Of Rights Of Recovery Agalnst Others To Us When We Do Not Renew.. SECTION V DEFINITIONS TABLE OF CONTENTS va 11UV Ve 19 S ECTION COVERAGES Beginning on Page Coverage A Bodily Injury and Property Insuring Agreement... Damage Liability Exclusions..... Coverage B Personal and Advertising Insuring Agreement... Injury Liability Exclusions Coverage C Medical Payments Insuring Agreement... Exclusions. Supplementary Payments SECTION Il WHO IS AN INSURED Bankruptcy Duties In The Event Of Occurrence Offense Claim Or Suit Legal Action Against Us. Other Insurance Premium Audit... Representations Separation Of Insureds Transfer Of Rights Of Recovery Against Others To Us When We Do Not Renew SECTION V DEFINITIONS... Beginning on Page Coverage A Bodily Injury and Property Damage Liability Coverage B Personal and Advertising Injury Liability Coverage C Medical Payments Insuring Agreement Exclusions.. Insuring Agreement Exclusions.. Insuring Agreement CGT0340219 | 2 |
COMMERCIAL GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY COVERAGE FORM 1 The bodily injury or property damage is caused by an occurrence that takes place in the coverage territory 2 The bodily injury or property damage occurs during the policy period and 3 Prior to the policy period no insured listed under Paragraph 1. of Section Il Who Is An Insured and no employee authorized by you to give or receive notice of an occurrence or claim knew that the bodily injury or property damage had occurred in whole or in part If such a listed insured or authorized employee knew prior to the policy period that the bodily injury or property damage occurred then any continuation change or resumption of such bodily injury or property damage during or after the policy period will be deemed to have been known prior to the policy period. Bodily injury or property damage which occurs during the policy period and was not prior to the policy period known to have occurred by any insured listed under Paragraph 1. of Section Il Who Is An Insured or any employee authorized by you to give or receive notice of an occurrence or claim includes any continuation change or resumption of that bodily injury or property damage after the end of the policy period. Bodily injury or property damage will be deemed to have been known to have occurred at the earliest time when any insured listed under Paragraph 1. of Section Il Who Is An Insured or any employee authorized by you to give or receive notice of an occurrence or claim 1 Reports all or any part of the bodily injury or property damage to us or any other insurer 2 Receives a written or verbal demand or claim for damages because of the bodily injury or property damage or 3 Becomes aware by any other means that bodily injury or property damage has occurred or has begun to occur. Various provisionsin this policy restrict coverage. Read the entire policy carefully to determine rights duties and what is and is not covered. Throughout this policy the words you and your refer to the Named Insured shown in the Declarations and any other person or organization qualifying as a Named Insured under this policy. The words we us and our refer to the company providing this insurance. The word insured means any person or organization qualifying as such under Section Il Who Is An Insured. Other words and phrases that appear in quotation marks have special meaning. Refer to Section V Definitions. SECTION COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of bodily injury or property damage to which this insurance applies. We will have the right and duty to defend the insured against any suit seeking those damages. However we will have no duty to defend the insured against any suit seeking damages for bodily injury or property damage to which this insurance does not apply. We may at our discretion investigate any occurrence and settle any claim or suit that may result. But 1 The amount we will pay for damages is limited as described in Section Il Limits Of Insurance and 2 Our right and duty to defend end when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments. b. This insurance applies to bodily injury and property damage only if CGT1000219 Page 1 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 0 |
COMMERCIAL GENERAL LIABILITY 3 Any statute ordinance or regulation relating to the sale gift distribution or use of alcoholic beverages. This exclusion applies only if you are in the business of manufacturing distributing selling serving or furnishing alcoholic beverages. For the purposes of this exclusion permitting a person to bring alcoholic beverages on your premises for consumption on your premises whether or not a fee is charged or a license is required for such activity is not by itself considered the business of selling serving or furnishing alcoholic beverages. d. Workers Compensation And Similar Laws Any obligation of the insured under a workers compensation disability benefits or unemployment compensation law or any similar law. e. Employer s Liability Bodily injury to 1 An employee of the insured arising out of and in the course of a Employment by the insured or b Performing duties related to the conduct of the insured s business or 2 The spouse child parent brother or sister of that employee as a consequence of Paragraph 1 above. This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury. This exclusion does not apply to liability assumed by the insured under an insured contract. f. Pollution 1 Bodily injury or property damage arising out of the actual alleged or threatened discharge dispersal seepage migration release or escape of pollutants a At or from any premises site or location which is or was at any time owned or occupied by or rented or loaned to any insured. However this subparagraph does not apply to i Bodily injury if sustained within a building and caused by smoke fumes vapor or soot produced by or originating from equipment that e. Damages because of bodily injury include damages claimed by any person or organization for care loss of services or death resulting at any time from the bodily injury. 2. Exclusions This insurance does not apply to a. C. Expected Or Intended Injury Bodily injury or property damage expected or intended from the standpoint of the insured. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or property. Contractual Liability Bodily injury or property damage for which the insured is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages 1 That the insured would have in the absence of the contract or agreement or 2 Assumed in a contract or agreement that is an insured contract provided that the bodily injury or property damage occurs subsequent to the execution of the contract or agreement. Solely for the purposes of liability assumed in an insured contract reasonable attorneys fees and necessary litigation expenses incurred by or for a party other than an insured will be deemed to be damages because of bodily injury or property damage provided that a Liability to such party for or for the cost of that party s defense has also been assumed in the same insured contract and b Such attomeys fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this insurance applies are alleged. Liquor Liability Bodily injury or property damage for which any insured may be held liable by reason of 1 Causing or contributing to the intoxication of any person 2 The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol or CGT1000219 Page2of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY b c d is used to heat cool or dehumidify the building or produced by or originating from equipment that is used to heat water for personal use by the building s occupants or their guests i Bodily injury or property damage for which you may be held liable if you are a contractor and the owner or lessee of such premises site or location has been added to your policy as an additional insured with respect to your ongoing operations performed for that additional insured at that premises site or location and such premises site or location is not and never was owned or occupied by or rented or loaned to any insured other than that additional insured or iii Bodily injury or property damage arising out of heat smoke or fumes from a hostile fire At or from any premises site or location which is or was at any time used by or for any insured or others for the handling storage disposal processing or treatment of waste If such pollutants are or were at any time transported handled stored treated disposed of or processed as waste by or for i Anyinsured or i Any person or organization for whom you may be legally responsible At or from any premises site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured s behalf are performing operations if the pollutants are brought on or to the premises site or location in connection with such operations by such insured contractor or subcontractor. However this subparagraph does not apply to Bodily injury or property damage arising out of the escape of fuels lubricants or other operating fluids which are needed to perform the normal electrical hydraulic or mechanical functions necessary for the operation of mobile equipment or its parts if such fuels lubricants or other operating fluids escape from a vehicle part designed to hold store or receive them. This exception does not apply if the bodily injury or property damage arises out of the intentional discharge dispersal or release of the fuels lubricants or other operating fluids or if such fuels lubricants or other operating fluids are brought on or to the premises site or location with the intent that they be discharged dispersed or released as part of the operations being performed by such insured contractor or subcontractor i Bodily injury or property damage sustained within a building and caused by the release of gases fumes or vapors from materials brought into that building in connection with operations being performed by you or on your behalf by a contractor or subcontractor or iii Bodily injury or property damage arising out of heat smoke or fumes from a hostie fire or e At or from any premises site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured s behalf are or were at any time performing operations to test for monitor clean up remove contain treat detoxify or neutralize or in any way respond to or assess the effects of pollutants. 2 Any loss cost or expense arising out of any a Request demand order or statutory or regulatory requirement that any insured or others test for monitor clean up remove contain treat detoxify or neutralize or in any way respond to or assess the effects of pollutants or CGT1000219 Page 3 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY b Claim or suit by or on behalf of any governmental authority or any other person or organization because of testing for monitoring cleaning up removing containing treating detoxifying or neutralizing or in any way responding to or assessing the effects of pollutants. g Aircraft Auto Or Watercraft Bodily injury or property damage arising out of the ownership maintenance use or entrustment to others of any aircraft auto or watercraft owned or operated by or rented or loaned to any insured. Use includes operation and loading or unloading. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supension hiring employment training or monitoring of others by that insured if the occurrence which caused the bodily injury or property damage involved the ownership maintenance use or entrustment to others of any aircraft auto or watercraft that is owned or operated by or rented or loaned to any insured. This exclusion does not apply to 1 A watercraft while ashore on premises you own or rent 2 A watercraft you do not own that is a 50 feet long or less and b Not being used to carry any person or property for a charge 3 Parking an auto on or on the ways next to premises you own or rent provided the auto is not owned by or rented or loaned to you or the insured 4 Liability assumed under any insured contract for the ownership maintenance or use of aircraft or watercraft 5 Bodily injury or property damage arising out of a The operation of machinery or equipment that is attached to or part of a land vehicle that would qualify as mobile equipment under the definition of mobile equipment if such land vehicle were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged or b The operation of any of the machinery or equipment listed in Paragraph f.2 or f3 of the definition of mobile equipment or 6 An aircraft that is a Chartered with a pilot to any insured b Not owned by any insured and c Not being used to carry any person or property for a charge. Mobile Equipment Bodily injury or property damage arising out of 1 The transportation of mobile equipment by an auto owned or operated by or rented or loaned to any insured or 2 The use of mobile equipment in or while in practice for or while being prepared for any prearranged racing speed demolition or stunting activity. War Bodily injury or property damage arising out of 1 War including undeclared or civil war 2 Warlike action by a military force including action in hindering or defending against an actual or expected attack by any government sovereign or other authority using military personnel or other agents or 3 Insurrection rebellion revolution usurped power or action taken by governmental authority in hindering or defending against any of these. Damage To Property Property damage to 1 Property you own rent or occupy including any costs or expenses incurred by you or any other person organization or entity for repair replacement enhancement restoration or maintenance of such property for any reason including prevention of injury to a person or damage to another s property 2 Premises you sell give away or abandon if the property damage arises out of any part of those premises 3 Property loaned to you 4 Personal property in the care custody or control of the insured CGT1000219 Page4 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY 5 That particular part of real property on which you or any contractors or subcontractors working directly or indirectly on your behalf are performing operations if the property damage arises out of those operations or 6 That particular part of any property that must be restored repaired or replaced because your work was incorrectly performed on it. Paragraphs 1 3 and 4 of this exclusion do not apply to premises damage. A separate limit of insurance applies to premises damage as described in Paragraph 6. of Section lll Limits Of Insurance. Paragraph 2 of this exclusion does not apply if the premises are your work and were never occupied rented or held for rental by you. Paragraphs 3 4 5 and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph 6 of this exclusion does not apply to property damage included in the products completed operations hazard. Damage To Your Product Property damage to your product arising out of it or any part of it. Damage To Your Work Property damage to your work arising out of it or any part of it and included in the products completed operations hazard. This exclusion does not apply if the damaged work or the work out of which the damage arises was performed on your behalf by a subcontractor.. Damage To Impaired Property Or Property Not Physically Injured Property damage to impaired property or property that has not been physically injured arising out of 1 A defect deficiency inadequacy or dangerous condition in your product or your work or 2 A delay or failure by you or anyone acting on your behalf to perform a contract or agreement in accordance with its terms. This exclusion does not apply to the loss of use of other property arising out of sudden and accidental physical injury to your product or your work after it has been put to its intended use. Recall Of Products Work Or Impaired Property Damages claimed for any loss cost or expense incurred by you or others for the loss of use withdrawal recall inspection repair replacement adjustment removal or disposal of 1 Your product 2 Your work or 3 Impaired property if such product work or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect deficiency inadequacy or dangerous condition in it. Personal And Advertising Injury Bodily injury arising out of persona and advertising injury. Electronic Data Damages arising out of the loss of loss of use of damage to corruption of inability to access or inability to manipulate electronic data. However this exclusion does not apply to liability for damages because of bodily injury. Unsolicited Communication Bodily injury or property damage arising out of any actual or alleged violation of any law that restricts or prohibits the sending transmitting or distributing of unsolicited communication. Access Or Disclosure Of Confidential Or Personal Information Bodily injury or property damage arising out of any access to or disclosure of any person s or organization s confidential or personal information. Asbestos 1 Bodily injury or property damage arising out of the actual or alleged presence or actual alleged or threatened dispersal of asbestos asbestos fibers or products containing asbestos provided that the bodily injury or property damage is caused or contributed to by the hazardous properties of asbestos. CGT1000219 Page 5 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY 2 Bodily injury or property damage arising out of the actual or alleged presence or actual alleged or threatened dispersal of any solid liquid gaseous or thermal irritant or contaminant including smoke vapors soot fumes acids alkalis chemicals and waste and that are part of any claim or suit which also alleges any bodily injury or property damage described in Paragraph 1 above. 3 Any loss cost or expense arising out of any a Request demand order or statutory or regulatory requirement that any insured or others test for monitor clean up remove contain treat detoxify or neutralize or in any way respond to or assess the effects of asbestos asbestos fibers or products containing asbestos or b Claim or suit by or on behalf of any governmental authority or any other person or organization because of testing for monitoring cleaning up removing containing treating detoxifying or neutralizing or in any way responding to or assessing the effects of asbestos asbestos fibers or products containing asbestos. Employment Related Practices Bodily injury to 1 A person arising out of any a Refusal to employ that person b Termination of that employment or c Employment related practice policy act or omission such as coercion person s demotion evaluation reassignment discipline failure to promote or advance harassment humiliation discrimination libel slander violation of the person s right of privacy malicious prosecution or false arrest detention or imprisonment applied to or directed at that person regardless of whether such practice policy act or omission occurs is applied or is committed before during or after the time of that person s employment or 2 The spouse child parent brother or sister of that person as a consequence of bodily injury to that person at whom any of the employment related practices described in Paragraph a b or c above is directed. This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the bodily injury. Exclusions c. through n. do not apply to premises damage. A separate limit of insurance applies to premises damage as described in Paragraph 6. of Sectionlll Limits Of Insurance. COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of personal and advertising injury to which this insurance applies. We will have the right and duty to defend the insured against any suit seeking those damages. However we will have no duty to defend the insured against any suit seeking damages for personal and advertising injury to which this insurance does not apply. We may at our discretion investigate any offense and settle any claim or suit that may result. But 1 The amount we will pay for damages is limited as described in Section Hl Limits Of Insurance and 2 Our right and duty to defend end when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments. This insurance applies to personal and advertising injury caused by an offense arising out of your business but only if the offense was committed in the coverage territory during the policy period. 2. Exclusions This insurance does not apply to a. Knowing Violation Of Rights Of Another Personal and advertising injury caused by or at the direction of the insured with the knowledge that the act would violate the rights of another and would inflict personal and advertising injury. CGT1000219 Page6 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY This exclusion does not apply to personal injury caused by malicious prosecution. Material Published With Knowledge Of Falsity Personal and advertising injury arising out of oral or written publication including publication by electronic means of material if done by or at the direction of the insured with knowledge of its falsity. Material Published Or Used Prior To Policy Period 1 Personal and advertising injury arising out of oral or written publication including publication by electronic means of material whose first publication took place before the beginning of the policy period or 2 Advertising injury arising out of infringement of copyright title or slogan in your adverisement whose first infringement in your advertisement was committed before the beginning of the policy period. Criminal Acts Personal and advertising injury arising out of a criminal act committed by or at the direction of the insured. Contractual Liability Personal and advertising injury for which the insured has assumed liability in a contract or agreement. This exclusion does not apply to liability for damages 1 That the insured would have in the absence of the contract or agreement or 2 Because of personal injury assumed by you in a contract or agreement that is an insured contract provided that the personal injury is caused by an offense committed subsequent to the execution of the contract or agreement. Solely for the purposes of liability assumed by you in an insured contract reasonable attorneys fees and necessary litigation expenses incurred by or for a party other than an insured will be deemed to be damages because of personal injury provided that a Liability to such party for or for the cost of that party s defense has also been assumed by you in the same insured contract and b Such attomeys fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this insurance applies are alleged. Breach Of Contract Advertising injury arising out of a breach of contract. Quality Or Performance Of Goods Failure To Conform To Statements Advertising injury arising out of the failure of goods products or services to conform with any statement of quality or performance made in your advertisement. Wrong Description Of Prices Advertising injury arising out of the wrong description of the price of goods products or services stated in your advertisement. Intellectual Property Personal and advertising injury arising out of any actual or alleged infringement or violation of any of the following rights or laws or any other personal and advertising injury alleged in any claim or suit that also alleges any such infringement or violation 1 Copyright 2 Patent 3 Trade dress 4 Trade name 5 Trademark 6 Trade secret or 7 Other intellectual property rights or laws. This exclusion does not apply to 1 Advertising injury arising out of any actual or alleged infringement or violation of another s copyright title or slogan in your advertisement or 2 Any other personal and advertising injury alleged in any claim or suit that also alleges any such infringement or violation of another s copyright title or slogan in your advertisement. Insureds In Media And Intemnet Type Businesses Personal and advertising injury caused by an offense committed by an insured whose business is 1 Advertising broadcastingor publishing CGT1000219 Page 7 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY 2 Designing or determining content of websites for others or 3 An Internet search access content or service provider. However this exclusion does not apply to Paragraphs a.1 2 and 3 of the definition of personal injury. For the purposes of this exclusion 1 Creating and producing correspondence written in the conduct of your business bulletins financial or annual reports or newsletters about your goods products or senices will not be considered the business of publishing and 2 The placing of frames borders or links or advertising for you or others anywhere on the Internet will not by itself be considered the business of advertising broadcasting or publishing. Electronic Chatrooms Or Bulletin Boards Personal and advertising injury arising out of an electronic chatroom or bulletin board the insured hosts or owns or ower which the insured exercises control. Unauthorized Use Of Another s Name Or Product Personal and advertising injury arising out of the unauthorized use of another s name or product in your e mail address domain name or metatag or any other similar tactics to mislead another s potential customers. Pollution Personal and advertising injury arising out of the actual alleged or threatened discharge dispersal seepage migration release or escape of pollutants at any time. Pollution Related Any loss cost or expense arising out of any 1 Request demand order or statutory or regulatory requirement that any insured or others test for monitor clean up remove contain treat detoxify or neutralize or in any way respond to or assess the effects of pollutants or 2 Clam or suit by or on behalf of any governmental authority or any other person or organization because of testing for monitoring cleaning up removing containing treating detoxifying or 0. neutralizing or in any way responding to or assessing the effects of pollutants. War Personal and advertising injury arising out of 1 War including undeclared or civil war 2 Warlike action by a military force including action in hindering or defending against an actual or expected attack by any government sovereign or other authority using military personnel or other agents or 3 Insurrection rebellion revolution usurped power or action taken by governmental authority in hindering or defending against any of these. Unsolicited Communication Personal and advertising injury arising out of any actual or alleged violation of any law that restricts or prohibits the sending transmitting or distributing of unsolicited communication. Access Or Disclosure Of Confidential Or Personal Information Personal and advertising injury arising out of any access to or disclosure of any person s or organization s confidential or personal information. Asbestos 1 Personal and advertising injury arising out of the actual or alleged presence or actual alleged or threatened dispersal of asbestos asbestos fibers or products containing asbestos provided that the personal and advertising injury is caused or contributed to by the hazardous properties of asbestos. Personal and advertising injury arising out of the actual or alleged presence or actual alleged or threatened dispersal of any solid liquid gaseous or thermal imitant or contaminant including smoke vapors soot fumes acids alkalis chemicals and waste and that are part of any claim or suit which also alleges any personal and advertising injury described in Paragraph 1 above. 3 Any loss cost or expense arising out of any a Request demand order or statutory or regulatory requirement that any insured or others test for monitor clean up remove contain treat detoxify or neutralize or in any way respond to or CGT1000219 Page8 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY assess the effects of asbestos asbestos fibers or products containing asbestos or b Claim or suit by or on behalf of any governmental authority or any other person or organization because of testing for monitoring cleaning up removing containing treating detoxifying or neutralizing or in any way responding to or assessing the effects of asbestos asbestos fibers or products containing asbestos. s. Employment Related Practices Personal injury to 1 A person arising out of any a Refusal to employ that person b Termination of that person s employment or c Employment related practice policy act or omission such as coercion demotion evaluation reassignment discipline failure to promote or advance harassment humiliation discrimination libel slander violation of the person s right of privacy malicious prosecution or false arrest detention or imprisonment applied to or directed at that person regardless of whether such practice policy act or omission occurs is applied or is committed before during or after the time of that person s employment or 2 The spouse child parent brother or sister of that person as a consequence of personal injury to that person at whom any of the employment related practices described in Paragraph a b or c above is directed. This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the personal injury. 3 Because of your operations provided that a The accident takes place in the coverage territory and during the policy period b The expenses are incurred and reported to us within one year of the date of the accidentand c The injured person submits to examination at our expense by physicians of our choice as often as we reasonably require. b. We will make these payments regardless of fault. These payments will not exceed the applicable limit of insurance. We will pay reasonable expenses for 1 First aid administered at the time of an accident 2 Necessary medical surgical X ray and dental services including prosthetic devices and 3 Necessary ambulance hospital professional nursing and funeral services. 2. Exclusions We will not pay expenses for bodily injury a. Any Insured To any insured except volunteer workers. b. Hired Person To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. Injury On Normally Occupied Premises To a person injured on that part of premises you own or rent that the person normally occupies. d. Workers Compensation And Similar Laws To a person whether or not an employee of any insured if benefits for the bodily injury are payable or must be provided under a workers compensation or disability benefits law or a similar law. e. Athletics Activities To aperson injured while practicing instructing COVERAGE C MEDICAL PAYMENTS or participating in any physical exercises or 1. Insuring Agreement games sports or athletic contests. a. We will pay medical expenses as described f. Products Completed Operations Hazard below for bodily injury caused by an accident Included within the products completed 1 On premises you own or rent operations hazard. 2 On ways next to premises you own or rent g. Coverage A Exclusions or Excludedunder Coverage A. CGT1000219 Page 9 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
COMMERCIAL GENERAL LIABILITY SUPPLEMENTARY PAYMENTS 1. We will pay with respect to any clam we investigate or settle or any suit against an insured we defend a. All expenses weincur. b. Up to 2500 for the cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds.. The cost of bonds to release attachments but only for bond amounts within the applicable limit of insurance. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or suit including actual loss of earnings up to 500 a day because of time off from work.. All court costs taxed against the insured in the suit. However these payments do not include attorneys fees or attorneys expenses taxed against the insured. f. Prejudgment interest awarded against the insured on that part of the judgment we pay. If we make an offer to pay the applicable limit of insurance we will not pay any prejudgment interest based on that period of time after the offer. g Allinterest on the full amount of any judgment that accrues after entry of the judgment and before we have paid offered to pay or deposited in court the part of the judgment that is within the applicable limit of insurance. These payments will not reduce the limits of insurance. If we defend an insured against a suit and an indemnitee of the insured is also named as a party to the suit we will defend that indemnitee if all of the following conditions are met a. The suit against the indemnitee seeks damages for which the insured has assumed the liability of the indemnitee in a contract or agreement that is an insured contract b. This insurance applies to such liability assumed by the insured c. The obligation to defend or the cost of the defense of that indemnitee has also been assumed by the insured in the same insured contract d. The allegations in the suit and the information we know about the occurrence or offense are such that no conflict appears to exist between the interests of the insured and the interests of the indemnitee e. The indemnitee and the insured ask us to conduct and control the defense of that indemnitee against such suit and agree that we can assign the same counsel to defend the insured and the indemnitee and f. The indemnitee 1 Agrees in writing to a Cooperate with us in the investigation settlement or defense of the suit b Immediately send us copies of any demands notices summonses or legal papers received in connection with the suit c Notify any other insurer whose coverage is available to the indemnitee and d Cooperate with us with respect to coordinating other applicable insurance available to the indemnitee and 2 Provides us with written authorization to a Obtain records and other information related to the suit and b Conduct and control the defense of the indemnitee in such suit. So long as the above conditions are met attorneys fees incurred by us in the defense of that indemnitee necessary litigation expenses incurred by us and necessary litigation expenses incurred by the indemnitee at our request will be paid as Supplementary Payments. Notwithstanding the provisions of Paragraph 2.b.2 of Section Cowverages Coverage A Bodily Injury And Property Damage Liability or Paragraph 2.e. of Section Coverages Coverage B Personal And Advertising Injury Liability such payments will not be deemed to be damages for bodily injury property damage or personal injury and will not reduce the limits of insurance. Our obligation to defend an insured s indemnitee and to pay for attorneys fees and necessary litigation expenses as Supplementary Payments ends when CGT1000219 Page 10 of 21 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office Inc. with its permission. | 1 |
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