Page 39 - Bernardon-AtlantiCare Manahawkin ASC RFP Response

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
05/03/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Penny S. Reeder, CIC, CISR
NAME:
Chester & Associates, LLC PHONE 610-383-3884 FAX 610-383-3886
50 South First Avenue (A/C, No, Ext): (A/C, No):
E-MAIL
Coatesville, PA 19320 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
RLI Insurance Company 13056
INSURER A :
INSURED Bernardon PC INSURER B : US Specialty Insurance Company 29599
10 North High Street INSURER C :
Suite 310
West Chester, PA 19380 INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
A COMMERCIAL GENERAL LIABILITY PSB0003203 05/01/2021 05/01/2022 EACH OCCURRENCE $ 2,000,000
DAMAGE TO RENTED 1,000,000
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
PRO- 4,000,000
POLICY JECT LOC PRODUCTS - COMP/OP AGG $
OTHER: $
A AUTOMOBILE LIABILITY PSA0001457 05/01/2021 05/01/2022 COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
$
A UMBRELLA LIAB OCCUR PSE0003020 05/01/2021 05/01/2022 EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTION $ $
A WORKERS COMPENSATION PSW0001911 05/01/2021 05/01/2022 PER OTH-
AND EMPLOYERS' LIABILITY Y / N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N / A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
B Professional Liability Claims-Made USS 21 31454 01/01/2021 01/01/2022 Each Claim $5,000,000
Aggregate $5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
S.A.M.P. L. E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD