CERTIFICATE OF LIABILITY INSURANCE (3)CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
05103I2016
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 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
MARSH USA INC.
540 W. MADISON
CHICAGO, IL 60fi61
Attn: chicago.CertRequest(�Dmarsh.com
INSURED
CorVel Healthcare Corporafion
Adn: Jay Villeda
2010 Main Street, Suite 600
Irvine, CA 92614
INSURER(S) AFFORDING COVERAGE
iNSUReR a: Travelers Properly Casualry Company of America
iNSUreeR e:� Specialry Insurance Company
iNSUrteR c: illinas Union Insurance Company
NAIC #
COVERAGES CERTIFICATE NUMBER: CHI-006039811-78 REVISION NUMBER:3
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEIOW 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 TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY El(P LIMITS
LTR POLICY NUMBER MM/DD/Yl'YY MM/DDIYYYY
A X COMMERCIAL GENERAL LIA&LITY TJGLSA280K509S16 O4/30/2016 04/30l2017 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE � OCCUR AMA E T RENTED
PREMISES Eaoccurrence $ ���0,«14
MED EXP (,any w,e Person) $ 10,000
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY ❑ jE � a LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILE LIABILlTY TJCAP280K51u"2-16 04130/ZO�B l�M3OlZO�7 CON181NED SIfJGLE LIFAI7 $ 'I,OOO,OOO
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
Comp.ICdl. Ded. S 500
B X UMBRELLA LIAB X OCCUR US00067014LI16A 04/30/2016 04�3O/2017 EqCH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MAOE AGGREGATE $ 1,000,000
DED X RETENTION $ iO OOO $
A WORKERS COMPENSATION TC2JU6280K5071-16 (AOS) OMSO/2016 04/30/2017 X STATUTE ERH
AND EMPLOYERS' LIABILITY
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N TRJUB280K5083-16 (AZ, MA, NE, WI� O4I3O/ZO1B O4I3O/ZO17
OFFICER/MEMBER EXCLUDED? � N/ A E.L. EACH ACCIDENT $ 1,000,000
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000
If yes, describe under �
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 'I,OOO,OOO
C Managed Healthc�e Prof. Liab. MSP G27108647 003 (SIR: $300,000) 10/31/2015 10/31/2016 Per Civm 5,000,000
Retro date: 0410-1987 Aggregffie 5,000,000
DESCW PTION OF OPERATIONS / LOCAT10N3 / VEHICLES �ACORD 701, Adtlkional Remarks Schedule, may be attached if more space is required)
City of Clearwater is Additional Insured with respect their interest.
CERTIFICATE HOLDER CANCELLATION
City of Clearwater
Atln: John Marcin
100 S. Myrtle Ave.
Clearwater, FL 34616
ACORD 25 (2014/01)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTFiORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukhery'ee ,.M,c��.n,��.: �iA.u..rce..�ew�.e.,c„
�O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD