2024.09.11_COI_CL_AL_WC.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

12/19/2023

Arthur J. Gallagher Risk Management Services, LLC 11550 Fuqua Street Suite 205 Houston TX 77034

Credentialing Team 281-674-1420 281-674-1460

GSHIS@AJG.COM

Fidelity and Guaranty Insurance Company 35386 THEOMED-01 State Automobile Mutual Insurance Co 25135

Theoria Medical PLLC 41800 W 11 Mile Road Suite 109.

Novi MI 48375

Travelers Property Casualty Co of America 25674 Homesite Insurance Company 17221 Underwriters at Lloyd's, London 32727

2080968645

A X 2,000,000 X 300,000

5,000

2,000,000

4,000,000 X

BIP7T005226 9/11/2023 9/11/2024

4,000,000

B 1,000,000

X X X

10119895CA 3/1/2023 3/1/2024

C X X 5,000,000CUP7T005275 9/11/2023 9/11/2024

5,000,000 X 5,000

C UB3W032241 2/1/2023 2/1/2024

1,000,000

1,000,000

1,000,000 D E

Professional Liability Sexual Misconduct & Molestation

PMC-144125084-00

MR237474

9/1/2023 9/1/2023

9/1/2024 9/1/2024

PL Each Claim:

PL Aggregate Limit:

Sexual Miscon Limits:

$2,000,000 $2,000,000 $1M/$3M

Certificate holder is included as Additional Insured on the Auto policy, as per form BA3000 12/15. Waiver of Subrogation applies to certificate holder, as respects to the Auto and Workers' Compensation policies, pursuant to and subject to the policy's terms, definitions, conditions and exclusions. The Umbrella follows form to the General Liability and Worker's Compensation policies.

COVERAGE IS LIMITED TO WORK ON BEHALF OF Theoria Medical PLLC. PROVIDER HAS SHARED LIMITS OF $2M/$2M ONLY WHILE WORKING AT

ARIZONA STATE VETERANS HOME.

All insured organizations, insured professionals, insured paramedicals/other covered employees will share in the limit of liability applicable to Theoria Medical, PLLC.

Theoria Medical PLLC See Attached...

Theoria Medical PLLC 41800 W. Eleven Mile Road, Suite 109 Novi MI 48375 United States

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

THEOMED-01

1 1

Arthur J. Gallagher Risk Management Services, LLC Theoria Medical PLLC 41800 W 11 Mile Road Suite 109.

Novi MI 48375

25 CERTIFICATE OF LIABILITY INSURANCE

41800 W 11 Mile Road Suite 109 Novi MI 48375 United States