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CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD[YYYY]
<br />11/21/2019
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT� Ii the Certificate holder is an ADDIT161NALINSURED, the policy must have ADDITIONAL INSURED provisions orb
<br />endorsed,
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such ondorsoment(s),
<br />m.muff
<br />-PRODUcER'
<br />The Horton Group 0AME;-
<br />P14ONE FAX
<br />340 Columbia Place (A)(„' 708-846-3917 AM No,„ a68-202-5917
<br />South Bend IN 46601 E-MAIL
<br />AaoRuSs! cen ifica he y the 11 Orton g roup. com
<br />0.NSURERtSyAFFORDINP COVERAGE NAIC 4
<br />INSURED 8 1 LACHEA-02 INSURER A: Medical Protective 11843
<br />Beacon Health System, inc.; Beacon: Medical Group; Memorial INSURER B: Amerisure Mutual insurance Co. 23396
<br />Hospital of South Bend, Inc,; Elkhart INSURER C
<br />General Hospjtal� Community Hospital of Bremen INSURfiR 0
<br />615 N Michi an Street INPlJRER 6
<br />South BendIN 46601
<br />COVERAGES CERTIFICATE NUMBER: 1732807401 R . EVI SIO N - N " UMBER I
<br />—is 'IF"'Y 7'H" "AT—T-i-I-E-,-POL—I,C--l-E—S-0-F-I-N--S",U"I-R-A--N--C",E- —LIS--TED BELOW HA-"V-"E-IBE—EN--ISSUED ---- ------
<br />TO THE INSURED NAMED ABOVE FOR THE POI ICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDFTIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />NSR t _ __ _', INSURANCE
<br />C AUDL 'SuOR POLI,CYQFF POLICYEXPE
<br />-!t.
<br />1kiiu liz
<br />A X COMMERCIAL GENERAL LIABILITY H002223
<br />-K OCCUR 1211/2019 12/1/2020 FACH OCCURRENCC $ I'"0'000
<br />kA GRAS WIDE L)AMA(f to ALNTEU
<br />.. T'1 lion Ann
<br />G[N`L AGGREG&TE LIMIT APPLIES PER:
<br />RO,
<br />Priory 1-1 JECT
<br />PLCC
<br />8 AUTOMOBILE LIABILITY
<br />ANY ALI jr(j
<br />X
<br />OWNED
<br />SCHrIDULLA)
<br />AUTOS OlIll Y
<br />AUTOS
<br />X
<br />HIRED X
<br />NON-Ovi
<br />AU1 OS ONLY
<br />AUTOS ONLY
<br />A X
<br />UMBRELLALIAB
<br />(K=R
<br />EXCESS LIAB
<br />UlAIM&MADC'
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETCRIPARTNER/EXECUTIVE
<br />OFFICERWEMBEREXCLUDED? ❑ NIA
<br />(Mandatory In NH)
<br />A Medical Malpractice Shared Limits
<br />Mad Malpractice Separate Limits
<br />MED EXP (Any one Person)
<br />$5.000
<br />PERSONAL & ADV IN4UAY
<br />$ 1,000,000
<br />GENERAL AGGREGATE
<br />s 3000'000
<br />PRODUGuS CONiii"OVAGG
<br />3,000,0100
<br />zozoCEa aculdu5 k, 11kr 17
<br />$1,000,000
<br />OCOILY INJURY (Per person)
<br />$
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTYDAMAGE
<br />$
<br />ex. danl,
<br />$
<br />E002223 12/1/2019 12/1/2020 EACH OCCURRENCE
<br />S 25,000,000
<br />AGGREGATE
<br />S 25,000,000
<br />STATUTE EA
<br />E1. EACH ACOOENT
<br />$
<br />EJ, OTbEASE-FAFMplow,
<br />I
<br />E1, DISEASE • POUCY LIMIT3
<br />;0-02-2"2-3-,
<br />19 1211/2020 riddew
<br />500,000
<br />" 09,1to
<br />15,000,000
<br />JA
<br />',NdanVA9gregae
<br />500,000/1,500,000
<br />ORSCRIPIIQNOFOPERATtONSlLOCATIONS IVtrliCtCS
<br />Additional Named Insure4s- Beacon Spe6afty Surgery Cenlev, LLC„ Beacon Health, ILLCBeacon Health Ventures, Inc.; Beacon Occupational Health, LLC.
<br />Qualified under the Indiana Patient Compensation Fund,
<br />Annual Parking Garage License: Centennial, Bartlett and Navarre Garages
<br />CERTIFICATE HOLDER
<br />CAN
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of South Bend ACCORDANCE WITH THE POLICY PROVISIONS.
<br />227 W. Jefferson Blvd.
<br />Suite 1400 South
<br />South Bend IN 46601
<br />. . ............... .
<br />(9) 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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