3-COI_BAFO #BPM006719_Statewide ERSS_AMI Expeditionary Health.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

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

4/4/2025

Arthur J. Gallagher Risk Management Services, LLC 1050 Crown Pointe Parkway, Suite 600, Atlanta GA 30342

Bianca Walsh 678-393-5274 bianca_walsh@ajg.com

Liberty Mutual Insurance Company 23043 AMIEXPE-01 Underwriters at Lloyd's London 15792

AMI Expeditionary Healthcare, LLC 12030 Sunrise Valley Drive Suite 400 Reston VA 20191

Republic-Vanguard Insurance Company 40479

23806608

B X 3,000,000 X

5,000,000 X

UA25RN461M5X 3/31/2025 3/31/2026

C

X X

CNO6290889-00 7/31/2024 7/31/2025

1,000,000

1,000,000

A X

N

WC5-33S-B23T70-024 7/18/2024 7/18/2025

1,000,000

1,000,000

1,000,000

Evidence of Coverage

B Healthcare Professional Liability UA25RN461M5X 3/31/2025 3/31/2026 Each Occurrence $1,000,000 (Medical Malpractice) Annual Aggregate $5,000,000

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

Medical services, staffing, case management and transportation

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE

DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

CANCELLATION

© 1993-2015 ACORD CORPORATION. All rights reserved.ACORD 27 (2016/03)

The ACORD name and logo are registered marks of ACORD

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 EVIDENCE OF PROPERTY INSURANCE 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 INFORMATION

LOCATION/DESCRIPTION

COVERAGE INFORMATION

COVERAGE / PERILS / FORMS AMOUNT OF INSURANCE DEDUCTIBLE

PHONE

(A/C, No, Ext):

(A/C, No):

FAX E-MAIL

ADDRESS:

AGENCY

THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST.

CUSTOMER ID #:

AGENCY

SUB CODE:CODE:

INSURED LOAN NUMBER POLICY NUMBER

TERMINATED IF CHECKED

CONTINUED UNTIL

EXPIRATION DATEEFFECTIVE DATE

THIS REPLACES PRIOR EVIDENCE DATED:

COMPANY

DATE (MM/DD/YYYY)

EVIDENCE OF PROPERTY INSURANCE

REMARKS (Including Special Conditions)

MORTGAGEE

ADDITIONAL INSURED LOSS PAYEE

ADDITIONAL INTEREST

NAME AND ADDRESS

AUTHORIZED REPRESENTATIVE

LOAN #

PERILS INSURED BASIC BROAD SPECIAL

LENDER'S LOSS PAYABLE

4/4/2025

678-393-5232 Arthur J. Gallagher Risk Management Services, LLC 1050 Crown Pointe Parkway, Suite 600 Atlanta, GA 30338

Covington Specialty Insurance Company 945 East Paces Ferry Road, Suite 1800 Atlanta, GA 30326

AMI Expeditionary Healthcare, LLC 12030 Sunrise Valley Drive Suite 400 Reston VA 20191

VBB161497

03/31/2025 03/31/2026

X

Building, Business Personal Property, Business Income: per occurrence limit $5,000 $1,000

Evidence of Coverage