YH25-0076-05_COI_Exp_071025.pdf
PDF 227 KB Posted
- Attached to
- Master Agreement AZ|CTR077411
- Contract number
- CTR077411
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by The Hartford Business Service Center on June 11, 2024, for Janine Roumain, MD, MPH. The insurance is produced through InsZone Insurance Services LLC, with Sentinel Insurance Company Ltd. as the primary insurer. The certificate is addressed to AHCCCS (Arizona Health Care Cost Containment System) located in Phoenix, Arizona, and references a specific contract number YH21-0005-06.
The insurance policy provides comprehensive coverage including Commercial General Liability, Automobile Liability, and Employment Practices Liability. The policy is effective from July 10, 2024, to July 10, 2025, with key coverage limits including $1,000,000 for each occurrence in general liability, $2,000,000 for general aggregate, and $10,000 for employment practices liability. The policy covers the insured's usual operations and is specifically tied to a contract with AHCCCS, with Sentinel Insurance Company Ltd. providing the insurance services through policy number 57 SBM UI2215.
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Other files
| File | Type | Posted |
|---|---|---|
| YH25-0076-05_COI_Exp_071026.pdf | ||
| YH25-0076-05_FE_Direct_Contract_for_Physician_Consultant_Services.pdf |
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Text version
WLTR005
THE HARTFORD
BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251 June 11, 2024
AHCCCS
701 E JEFFERSON ST MD 5700
PHOENIX AZ 85034
Account Information:
Policy Holder Details : JANINE ROUMAIN, MD, MPH Contact Us
Need Help?
Chat online or call us at
(866) 467-8730.
We're here Monday - Friday.
Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns.
Sincerely, Your Hartford Service Team
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
06/11/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS 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
INSZONE INSURANCE SERVICES LLC
57129672
2721 CITRUS RD SUITE A
RANCHO CORDOVA CA 95742
CONTACT NAME:
PHONE
(A/C, No, Ext):
(877) 308-9663 FAX
(A/C, No):
E-MAIL ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC#
INSURER A : Sentinel Insurance Company Ltd. 11000
INSURED
JANINE ROUMAIN, MD, MPH
901 W AVALON DR
PHOENIX AZ 85013-4015
INSURER B :
INSURER C :
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
LTR
TYPE OF INSURANCE ADDL
INSR
SUBR
WVD
POLICY NUMBER POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/Y YYY)
LIMITS
A
COMMERCIAL GENERAL LIABILITY
57 SBM UI2215 07/10/2024 07/10/2025
EACH OCCURRENCE $1,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED
PREMISES (Ea occurrence) $1,000,000
X General Liability MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY PRO-
JECT X LOC PRODUCTS - COMP/OP AGG $2,000,000
OTHER:
A
AUTOMOBILE LIABILITY
57 SBM UI2215 07/10/2024 07/10/2025
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000 ANY AUTO BODILY INJURY (Per person)
ALL OWNED
AUTOS
SCHEDULED
AUTOS BODILY INJURY (Per accident)
X HIRED
AUTOS X NON-OWNED
AUTOS
PROPERTY DAMAGE
(Per accident)
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-
MADE
EACH OCCURRENCE
AGGREGATE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY
PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below
N/ A
PER
STATUTE
OTH-
ER
Y/N E.L. EACH ACCIDENT
E.L. DISEASE -EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
A EMPLOYMENT PRACTICES
LIABILITY
57 SBM UI2215 07/10/2024 07/10/2025 Each Claim Limit Aggregate Limit
$10,000 $10,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Those usual to the Insured's Operations. RE: Contract Number: YH21-0005-06.
CERTIFICATE HOLDER CANCELLATION
AHCCCS
701 E JEFFERSON ST MD 5700
PHOENIX AZ 85034
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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