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Home My WebLink About20130591.tiffDEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, CO 80631 Public Health Web: www.weldhealth.orq Health Administration Public Health S Clinical Environmental Health Communication, Emergency Preparedness Vital Records Services Services Education & Planning & Response Tale: 970 304 6410 Tale: 9703046420 Tele. 970 304 6415 Tele. 970 304 6470 Tele: 970 304 6420 Fax: 970 304 6412 Fax 970 304 6416 Fax' 970 304 6411 Fax: 970 304 6452 Fax: 970 304 6469 Our vision Together with the communities we serve, we are working to make Weld County the healthiest plats to we, learn, work and play December 21, 2012 Steve Main (via email at scm@pvhs.org) Poudre Valley Hospital Emergency Medical Service 2315 East Harmony Road, Suite 200 Fort Collins, Colorado 80528 Subject: Ambulance Service License Application — Poudre Valley Hospital EMS Dear Mr. Main: The Weld County Department of Public Health and Environment has reviewed your application, submitted on November 8, 2012, for an Ambulance Service License. I am hereby denying the application. The application is being denied for the following reasons: • Poudre Valley Hospital EMS (PVH EMS) does not have its primary base of operation located in Weld County, as required by the definition of "ambulance service license," found in Section 7-1-30 of the Weld County Code, and, • PVII EMS is not providing "primary care" in Weld County, as defined in said Section 7-1-30, because it does not have an agreement or contract with Weld County to do so. If PVH EMS wishes to appeal this decision to the Board of County Commissioners, it may do so by availing itself of the procedures found at Section 2-4-10 of the Code, a copy of which is enclosed herein. If you have any questions, please contact Trevor Jiricek of my staff at 970-304-6415, X2214. Sincerely, 11,10411 Mark E. Wallace, MD, MPH Executive Director and Health Officer Ec: Bruce Barker, Weld County Attorney 2013-0591 ,AFL Ce*/ WELD COUNTY CODE (available on-line at www.co.weld.co.us) Sec. 2-4-10. Appeals process. The Board of County Commissioners shall act as a board of appeals to hear complaints on actions taken by County boards, commissions and departments. Except for decisions made by the Board of Adjustment and Uniform Building Code Board of Appeals, procedure for appeals shall be as set forth in this Chapter, by resolution of the Board, or as otherwise provided by law. A. Any person appealing an action by a County board, commission or department to the Board of County Commissioners shall file such a complaint, in writing, with the Clerk to the Board within sixty (60) days of the incident in question. B. Such complaint shall include: 1. The name of the employee, board, commission or department against which the complaint is made. 2. A description of the basic facts involved in the complaint. C. The Clerk to the Board shall schedule a hearing with the Board of County Commissioners, to be held within fifteen (15) days of the filing of the complaint, and shall notify all parties involved in the incident. D. The Board of County Commissioners shall hear all the available facts pertinent to the incident, may schedule a second hearing within thirty (30) days following the initial hearing if the Board determines such a need, and shall render a determination within thirty (30) days of the final hearing. E. No person shall be denied the right to appeal, provided that he or she complies with the administrative procedures established by the Board. (Weld County Codification Ordinance 2000-1) Page 2 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, CO 80631 Web. www.weldhealth.orq Public Health Health Administration Puene Heats I CllNcsl Environmental Health COmmunicMbn, Emergency Preparedness Vital Records SeMaa SONIC*, Education & Planing &tampon Tele 970.304.8410 Tel:970.3048420 TN9: 970 3046415 Tale: 970.304.8470 Tale. 970304.8420 Fax: 970 304.6412 Far. 970 304.6416 Fax: 970.3046111 Fax 970 304.8452 Fax: 970.304.6469 Cur non: Together with the ccmmurubes we serve, we are waking to make Weld County the Mal:h eal pace hp We. loam. work and play AMBULANCE SERVICE LICENSE APPLICATION ./ j Date of application: Name of Ambulance Service: J V�l�l e t 4 /iC y HS?r td // F PIS Owner: Name: P ✓of/u 1/4-44 e .' Address: a. 3'S L£ /144 many kW- Sia aa0 (x' Sag) Phone Number. (�/ 70 .2 3 -1 -1 50 I Operations Manager: q I ^ !S Name: _ J Q Ce. t 4 k . 13 RAO- " Address: ) o 17 S 'L .cry p 41/4„( 130 S t Phone Number: (1. 7 0, ),: -/Fs-- F S' Pursuant to Section 7-2-150 of Weld County Code Ordinance, any change of ownership requires a new application for ambulance service license. Date Received: / / (For Office Use Only) Documents Checked: Remarks: Approved Recommended (YIN): Date Referred to B.O.C.C.: / / Licensing Agent Page 3 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownerspinterfst(ifapplicable): o tlaf t< O a llS2e f f ea-.Q,ti WaecO C��X WeldCountywill be served by `ip company? Please attach h a pink indicating the ary;. /J ,9 / 4/ ! r -Can c ri- `Q�- ( Q t alt) I f How many ambulaNces do you operate? iO Location and description of the place(s) from which this ambulance service will operate. If there are more than two locations, attach a separate sheet with the above information. Location #1 Street Number: City: Location #2: Street Number: State: U Phone:(g90J .392 -?32 0 City: State: Phone: Medical Director: Name: Mailing Address: /0a (/ ra-ag1 S - 06 -n - 740-e 0-e Phone Number: q70 o Please read carefully : 2,052y 7-2-170 Annual renewal. All licenses and permits shall be renewed annually, shall expire on December 31 of the year issued, and shall not be renewed until the application has been approved by the Department. All applications for renewal of licenses and permits shall be made not later than sixty (60) days prior to the date of expiration. The Department shall notify, by certified mail, return receipt requested, each licensee of the renewal requirements of this section within ninety (90) days prior to the date of expiration (Weld County Code Ordinance 2007-8) 7-2-180 Change of Medical Director An ambulance service must report any change of medical director, including name, address and telephone number, to the Director within fifteen (15) calendar days of such change. (Weld County Code Ordinance 2007-8) Page 4 Please read carefully and provide the following: G. As required in Section 7-2-90 (G) of the Weld County Code Ordinance, a list of all emergency medical service providers who may be called upon to respond to an emergency with the ambulance service. This list shall include the following information on each person: 1. Complete name, address and date of birth 2. The highest level of certification, licensure or training attained. 3. A copy of current EMT -B, EMT -I or EMT -P certificate issued by the Colorado Department of Public Health and Environment; nurse licensure or an Advanced First Aid card from the American Red Cross; or a First Responder course completion certificate issued by a Division -recognized training center or training group. 4. Proof of valid Colorado driver's license. 5. A statement of criminal complaint or convictions, including Class 1 and II traffic violations, within the previous twelve (12) months. * H. As required in Section 7-2-90 of the Weld County Code Ordinance, Proof of insurance, as required in section 7-3-60 of this Chapter. (Worker's compensation insurance, Public liability and property damage bodily injury, Property damage, Professional liability, and Ambulance vehicles coverage.) I. As required in Section 7-2-90 (1) of the Weld County Code Ordinance, provide a current copy of EMT or Paramedic protocols adopted by the ambulance service in accordance with standards approved by the ambulance service's medical director. J. As required in Section 7-2-90 (J) of the Weld County Code Ordinance, provide a current copy of the ambulance service's training standards in accordance with the requirements approved by the ambulance service's medical director. All training must be through a state -certified emergency medical services training center. K. As required in Section 7-2-90 (K) of the Weld County Code Ordinance, make available for review by the Department current records of compliance with the current EMS Laws. L. As required in Section 7-2-90 (L) of the Weld County Code Ordinance, copies of any judgments entered against the licensee or license applicant within the previous twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. M. As required in Section 7-2-90 (M) of the Weld County Code Ordinance, such other information as the Department may require to make a fair determination. N. As required in Section 7-3-110 of the Weld County Code Ordinance, make available for review by the Department evidence of a medical continuous quality improvement program consistent with the requirements defined in the Colorado Board of Medical Examiners rules, 3 C.C.R § 713-6, Rule 500, 3.2, b. (Weld County Code Ordinance 2007-8) O. As required in Section 12.9.2 E I of the Colorado Rules Pertaining to Emergency Medical Services, provide a current copy of the ambulance service's pharmacological agents and delivery devices per medical director protocol. * Please note Section 7-3-50 Criminal record of ambulance crew member. Unless waived by the Board of County Commissioners, no person shall be employed by an ambulance service as an ambulance crew member who has been convicted of any of the following offenses within the previous twelve (12) months from the date of application: felony, misdemeanor or Class I or Class II traffic offense. Page 5 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-8-10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. Signature of Applicant Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS C +h 0gttun lin DAY k \ f aril bet , 30 1 r3- , IN THE COUNTY OF �I' {Zt' q 1MQP ,STAT:�FCOLORADO. *OTAgy` .1* PUBLIC ibiN�i pF 000 MIN EXPO I Signatur My Commission expires: f b / 1 / / 3 UNIVERSITY of COLORADO HEALTH Weld County, Dept of Public Health and Environment 1555 North 17th Avenue Greeley, CO 80631 November 8, 2012 'fo Whom It May Concern: Pursuant to the requirements of Section 7-2-90 of the Weld County Ordinance, Poudre Valley Hospital Ambulance Service (owned and operated by Poudre Valley Hospital) attests to the following: • No employees of Poudre Valley Hospital Ambulance Service have had any criminal complaints or convictions, including Class I or II traffic violations within the past twelve (12) months. • No employees of Poudre Valley Hospital Ambulance Service have had any judgments against their licenses within the past twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. Sincerely, Pried( ktch-aixot Brenda L Harstad, RN CHC Ethics/Compliance & Privacy Officer University of Colorado Health 2315 E. Harmony Road • Suite 200 • Fort Collins, CO 80528 • pvhs.org POUDRE VALLEY HEALTH SYSTEM Poudre Valley Health Emergency Medical Service 1024 S. Lemay Ave Ft.Collins, CO 80524 To whom it may concern; The training standards for Poudre Valley Emergency Medical Service, follows and/or exceeds all National Registry and Colorado State guidelines. Poudre Valley Health EMS is a registered training center with the state of Colorado. If you have any questions or concerns regarding this letter, please contact our Medical Director and/or Education Coordinator. State Training # CO -081 Medical Director: Dr. David Farstad fars@pvhs.org Education Coordinator: Kevin Burgess kjb1l@pvhs.org Sincer , Stev Main EMS Director 1024 South Lemay Avenue • Fort Collins, Colorado 80524-3998 • vvvvw pvhs.org POUDRE VALLEY HEALTH SYSTEM 11/9/12 Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley, CO 80631 To Whom It May Concern, Regarding our QA/QI policy: We QA 100% of all: Cardiac Alerts Cardiac Arrests Stroke Alerts SCT (specialty care transfers) LTTA (limited trauma teams) FTTA (full trauma teams) Refusals and Emergent Returns Additionally, we QA our new employees (100% for 6 months after FTO field training), and on request from the medical director other types of calls or personnel are QA'd. Thank You, RYfiv— Judith A. Bratten Supervisor of EMS Operations PVH EMS 1024 S. Lemay Ave Ft. Collins, CO 80524 (970)495-8019 20011A..4 Poudre VaNey Hospital • 1024 S. Lemay Avenue • Fort Collins, Colorado 80524 • Phone: (970) 495-7345 Medical Center of Rockies • 2500 Rocky Mountain Avenue • Loveland, Colorado 80538 • Phone: (970) 824-1370 APPLICATION FOR AMBULANCE SERVICE LICENSE AND AMBULANCE PERMITS Check one: New Application X _ Date: 11/9/12 SERVICE DEMOGRAPHICS Company name (owner/parent Company) _Poudre Valley Healthcare, Inc. Renewal Application Address 2315 E. Harmony Rd. Suite 200 City Fort Collins State CO Zip Code _80528 Telephone number (970) 232-1750 Fax Number (970) 495-7667 E -Mail _scm@pvhs.ore Doing Business as (AKA) _Poudre Valley Hospital EMS Address 1024 S. Lemay Ave City Fort Collins State CO Zip Code _80524 Telephone number (970) 495-8094 Fax Number (970)495-7667 E -Mail jab4@pvhs.org Applicant Name Judith A. Bratten, Supervisor of Operations Address _1024 S. Lemay Ave City _Fort Collins State CO _ Zip Code _80524 Telephone number _(970)195-8019 Fax Number _(970)495-7667 Email _jab4@pvhs.ore Physician Advisor/ Medical Director _David Farstad Medical License Number 34962 Address _1024 S. Lemay Ave City Fort Collins State CO Zip Code _80524_ Facility Affiliation _Poudre Valley Health System_( PVH and MCR ) Address _1024 S. Lemay Ave. City Fort Collins State CO Zip code 80524 Telephone Number (970)495-8006 Fax Number _(970)495-7641 E -Mail FARS@pvhs.org Manager or individual responsible for operation of service: Name _Steven C. Main Address _1024 S. Lemay Ave. City _Fort Collins State CO Zip Code 80524 Telephone number _(970)232-1750 or (970)391-9827 cell Fax Number (970)495-7667 E -Mail scm@pvhs.org Training and Experience: BA, NREMT-P, 28 yrs EMS EMS; 17 years EMS management 1 Address: 6909 10t" ST City Greeley Telephone number (970)392-4320 Service Area(s) see above Dispatch Locations: (please complete the following information on location, or provide an attached list with the same information) Descriptor (if applicable) PECC (100) Address 2221 S. Timberline Rd Fort Collins State CO Zip Code80525 Telephone number_(970) 416-1985_or 911 Service Area(s) PVHS Health District Unit numbers available for dispatch (or "all") _ALL Descriptor (if applicable) Larimer County Dispatch_(900)_Address_2501 Midpoint Dr. City _Fort Collins State CO_ Zip Code 80525 Telephone number_(970) 416-1985 Service Area(s) PVHS Health District City Unit numbers available for dispatch (or "all") ALL Descriptor (if applicable) Greeley ER and Surgical Center, Poudre Valley Health System State CO `s " -3, Unit numbers available for dispatch (or "all") All; (primarily Med 23) Descriptor (if applicable) Address City State Zip Code Telephone number Service Area(s) Unit numbers available for dispatch (or "all") INSURANCE (Please provide the name(s) for your insurance provider(s) for the service and vehicles, and attach policies) Insurance Company _Drown and Brown Safety Inc- Safety National (720) 489-9300 ext 25 Address _4532 Boardwalk Dr Suite 200 City Fort Collins State CO_ Zip Code 80525 Insurance Company : Flood and Peterson (Professional Liability) Address 4821 Wheaton Dr City Fort Collins State _CO_ Zip Code 80528 (970) 266-7123 2 m 0) em C E� 2 C C w 0 O a J W h w w a a a i m a) w N C m C y$ y 5 y2 p_, U'. _ m m O m 0 m 0 00 ID U a=a°=a=°=°O= M M O M 0 M M M It 0 0 CC CY ft 0 W 0 0 7 3 N co N 0 O O 1D7HU18D24S617775 0 O a E co It 2B4FP2532VR180189 O)) W C Cu03 0 2FAFP72W85X155412 O W N 0 N C C 0 u 5 O 0 1GKFK16K5NJ728454 U 2 O) 0) CO .0 3 .O U M N V 0 0 W W 2 e0 O) 0 0 W W U = 15 co TO 2 C d « > N > m > N m U 00000 ° a° m a° "I a w m w w w CV ❑ O W W > m> 2 ToNli N M N M M o F co I n 0 wwl'w co 0) o N its N =I N= W. 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O N L >`il co O C O N gN N C.:15W 2 (7 2 D m a ❑ a Z CO Y CO a C 0_' 3 0 a -1 ¢ 1 0 -O) m a RI w w 0 LAST NAME >' U) O - ' ▪ 0 N N uD, oI ) (\) I CO. r 2/10/2014 06-060-0413 2/27/2014 04-314-0860 N m F F- 2 W W W O O) OD W O) 0) as N 2/24/2013 Y 1/24/2015 92-285-1756 4/28/2013 92-259-4652 5/12/2017 Y > v 0 N W 3/31/2014 94-350-2349 ✓ O) o U U) • CD O4 N 963 EMT -P 971 EMT -P 958 EMT -P V N N N ▪ N N O 0 til O LO 0 O 0 O OD co co co co O 0 0 0 0 L Whitmore 5313 NCR 11 Co x c `w c o v U O 900 Marshall St. a)' m E o E _V C 0E Eo ' Y N RP 2 0 —aI w > a) m )a O ▪ aJ Y U U' f= POUDRE VALLEY HEALTH SYSTEM Poudre Valley Hospital Ambulance Service Medications Required by Protocol _ Acetylsalicylic Acid (Aspirin) Adenosine (Adenocard) Albuterol _ Albuterol /Ipraropium-DuoNeb Amiodarone Atropine _ Calcium Chloride Dextrose 50% Diphenhydramine (Benadryl) _ Dopamine (Intropin) _ Epinephrine (Adrenaline) 1:10,000 Epinephrine (Adrenaline) 1:1,000 Fentanyl (Sublimaze) _ Fumsemide (lasbc) _ Glucagon _ Glucose (15) _ Lidocaine (Xylocaine) _ Lorazepam (Ativan) _ Magnesium Sulfate Maluutol Methyprednisolone (Sold-Medrol) ^_ Midazolam (Versed) _ Morphine Sulfate Naloxone Noreen) _ Nitroglycerin (paste and spray) _ Olnnzapino(Zyprexa) Ondansetron (ODT/vial) (Zoifran) _ Oxygen (portable) Oxytocin (Niacin) _ Phenylephrine Intranasal _ Racemic Epinephrine _ Sodium Bicarbonate Terbutaline _ Vasopressin (Petressin) Supervisor Rigs (EMS1 and Med 18 EMS2) _ Atropine & Pralidoximine (Doudote) Cyanokit David Farstad, M.D. 11/20/2012 PamirsWI* Hospllal • 1024 S. Limey Avenue • Fon Collins, Colorado 80624 • Phone: (970) 405.7346 medical Center of Rockies • 2600 Rocky Mountain Avenue • Loveland, Ccendo 60538 • Phone: (070) 024-1370 POUDRE VALLEY HEALTH SYSTEM IP 11/26/12 PVH EMS BLS MED LIST / Albuterol Aspirin D50 Olutose/ oral glucose J Haman J Oxygen !/ , 12/ /2012 David Farstad, M.D. r aal Pouch Valley Hotptal • 1024 S. Limey Avenue • FOR Corns, Colorado 60621 • Phone: (970) 4954345 Medical Celle! of Rockies • 2600 R0dty Mountain Avenue • Loveland, Colorado $0599 • Phone: (970) 6241370 POUDRE VALLEY HEALTH SYSTEM 11/16/2012 Weld County Dept. Of Public Health & Environment 1555 North 17th Ave. Greeley, CO 80631 Kevin, Per our phone conversation on 11/14 here is the info requested re: our ambulance station locations. As stated in that phone call, we do not have assigned vehicles (numbers) to any particular station. Our "station locations" and the "potential number" of ambulances located there, are as follows: Our main station: 3509 S. Mason St. #9 Fort Collins, CO 80525 12 ambulances 415 S. Bryan St: 1 ambulance FC, CO 80521 913 E Myrtle St.: 2 Ambulances and 1 TEMS Ambulance FC, CO 80524 PVH Harmony Campus: 1 Ambulance 2127 E. Harmony Rd. FC, CO 80528 The "New" station in Greeley: 1 6906 10i° St. Greeley, CO 80634 Thanks and if more info is needed please contact me. dith A. Bretton Supervisor of EMS Operations PVH EMS 1024 S. Lemay Ave. (970)495-8019 Poudra Valley Hospital • 1024 S. Laney Avenue • Forl Collins, Colorado 10624 • Phone: (070) 405-7346 Medical Center of Rockies • 2500 Rocky Mount&Avenue • Loveland, Colorado 005311 • Phone: (070) 024-1370 7 d E J M mu e J Q_ PVH EMS FLEET 'C a. a(<ptapatgp�fpc.taagasagaaa N N N NN N N NN N NN N. N N N N N 0 0 co z 8 M O n 0 CO z 8 M a a n 12 0 U, z 8 M O 0 0 n O 8 8 M O r 0 re 0 0 0 Grp 8 a 0 co n 0 N z M N or en M O O) O O N 0 W 0 LL ao O co M 2 0 M I- M or co 0 a rn a n tp 8 M O M 0 0 0 0 co coM t2p 8 M r O r r M U) or 0 a a O M CO 03 N U- 0 0 0 M 0 co a a X O LL r N. 100 r 0 0 M O re CD O O _n CO W CO H 0 r 0 03 CO W 0 N or CI 0 n 0 CO 0 M O M N 8 a co z 8 M r O M N. a N z 8 M r 7- or C9 0 a N M 0 W 00 CO 01 O I 0 LL IE BEE a C co e 3 .0 3 Cn 0 5 .0 Q O LU 0 V 0 0 0 0 0 0 W gZ5 CO Q CO 2 CO CO W 0 g m 20 5 mm 552 Q Q Q O N N z 8 M or a O M M O LU N CC N. r M Oa) 2 0 N en co • co 88 12 O) a Z 8 CZ CtWCC 0000 N DMDD 7 N imp 00 O co O O OCD C3 CD N N N 0 CO 0 N N or 0 0 0 0 M LL N O N W W W W W W W W W W W W 000000000000 z 555555555555 C) 0 CO CO C) CO CO CO CO CO CO co 222222222222 <<<<<<<<s<<< 0,QO •_cp agli Q -'N ` 7t 0.. W W W W W W W N w a v y CO I W O N V S d S N S 2012 Poudre Valley Hospital EMS FLEET ||J |!!,! | |||||||||||||||||| �x�l�■��l��l�#�t u I\}»i»I\|� ! l !!!!!!!!!!!! u inn n | || | |\n\l/I ! | -,■__§§-§§■�, li ii ill ;ii 11 IGKFK1nCSNJ77617. 10WOR FLOCE45,43H82,716 061 UGR IFOSSS/PY6NR06W 037UCR 1 /\w2;�\ I25=:2| }\ .>.: .� p K \:\ ,. x z, | I I«!!!!!!!!!:!!!|!|| I ■ | | | di !il !| at || |||||||11§§i ■|■|||: Fah!! H`:j �ff ||,Irk" Mils W || �1 M lS ”all | Dan M06 means ?S at toter 9M61Cn ! I IIIHNIMINH hilliiiiiiiiiiiii r//5- .5 Sy , mapquest !Loveland. /pm pin S S 3f 3 (257) Windsor Snara nua ef (392 -i ;02012 Mapquatt Paillans 02012 NAY TE.Q POUDRE VALLEY HEALTH SYSTEM 11/16/2012 Weld County Dept. Of Public Health & Environment 1555 North 17'h Ave. Greeley, CO 80631 Kevin, I have attached a usable drug check off (list), for ambulance inspections; a map (and addresses) of our station locations; an updated fleet list to include date placed in service and 4x 4 capabilities. Also, for the response area from the Greeley address, it will be the attached map of a 35 mile radius (from 6906 10th St, 80634), so that it includes areas of return: to skilled nursing facilities, rehabs etc. Thanks for all your help and patience with me getting all the info to you in the manner you require. If more info is needed please, contact me, asap. Judt�Bratte�� Supervisor of EMS Operations PVH EMS 1024 S. Lemay Ave. (970)495-8019 Poudre Valley Hospital • 1024 8. Lemay Avenue • Foil Count, Colorado 80624 • Phone: (970) 496.7346 Medical Center of Roddes • 2500 Rocky Mounts Avenue • Loveland, Colorado 80538 • Phone (970) 824.1370 POUDRE VALLEY HEALTH SYSTEM 2r4 Poudre Valley Hospital EMS Drug List (minimum carried in each in service Ambulance) `(3) Adenosine (2) 6mgs, (I) 12mg `(3) Albuterol ^(3)Albuterol / Ipraropium-DuoNeb \(8)Asprin (6 }Atropine (2 )Calcium Chloride (2 )D50 ` (2 )Diphenhydramine ` (1 )Dopamine -(2 )Epinephrine (1:1000) " (8 )Epinephrine (1:10,000) N- (2 )Epinephrine (racemic) (2 )Fentanyl `(2)Furosemide `(1)Glucagon `(3)Glutose 15 ` (3 )Lidocaine Poudre Valley Hospital • 1024 S. Lemay Avenue • Fort Collins, Colorado 00624 • Plane: (070) 406.7746 Medical Center of Recites • 2500 Rocky Mountain Avenue • Loveland Colorado 80639 • Phone: (970) 624-1370 Go,, igle Address 6906 10th St Greeley, CO 80634 Get Goggle Mapson your phone gTextee wad 'GMAPS" to 466453 Ca Rd/J W g w o s 2 S 1'14! WCR31 5YJ Weld l.wt/ R04455 WIn060f 14 f Yd51a1 Pal CI Co R412 - Man Rlt.xn, G0lCP:fse i 1 Ce!IJd4 q1 (5_]1 'MR OS s p ost q Osl Vl.W cat", Raadd6 7 t eee ?Rots( S Co Rd Be I SI N ,0,41. 5 A' Ca RS td 11th 31 WJBSi SI :nwII :!l Jan al; 2'1115t ce"c JJ e. R45-0 ?Chet Lx RJ SR. 6 Co Rd 54 Co Ade& 'a 4 Wirth S1 4:1, 51 g J -o Cea i 6e Ierr 51 l 1 Ih 51 Greeley i SA 51 Co RJ!e Gd41" CM. VIA a O Evans 3 -I W Soot aw 0AF• 41c, Re 124 Oise' e4 S a 'O2011 GoW4 • Map dataOx012 G000gl. Page II DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1655 North 176Avenue Greeley, CO 80631 Web: www.weldheeilh.org lion Monkish**, rlamalMs i Oaetn aMaaanwl Kalb OennwAmOM, Eewingfgn.e.es MMm*Afe anises Swim Menke Fbeslry tan pope 111t 603011410 rN:60►01M30 TO; 1N.301141► TM:a10S01MI0 it Mr0 fat 1141011111 fix 10U14% Far 0/03010/11 Fa faWaufi FIE 170.301.0149 QV War !Watt M OMa'agU wpm. asIMO .weep emit. lrivQW4yftMNlulphn bnRMrq %ora Mopr. Eu6lio .11te LOCAL FIRE DEPARTMENT APPROVAL Please complete the following Information and have your local lire authority representative complete the section Indicated. /knee the form is completed submit to the address stated below. Ambulance Service Nemo: Ambulance Service Address: Q City: Gam- Stale Zip Code: � Phone Number: (9 16,6 V (393 Tau LD. Number: Seating Capacity: S Uc)& �fwllauY�tliY1 S 6`166 /o8 c4-. THIS SECTION TO BE COMPLETED BY FIRE DEPARTMENT Cheer one of the following: The above named establishment meets the requirements for Fire Department approval without (briber action by establishment. o The above named establishment does not meet the requirements for Fire Department approval. o Please see attached letter. Comments: Fire Inspector Name Fire Inspector Sigma Local Jurisdiction: Title _ Date: gilWiren)flakinhone Number: Li Plena Remit to Weld County Department of Public Health & Envhronmenl Anit: Environmental Health Services ISM N. 17th Avenue Greeley, CO $0631 Phone (970) 304-6115 Fax (970)30.1-6411 g.' Page 12 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17" Avenue Greeley, CO 80831 W& lNww.weldheaNh.org Ne1NAlmkt*VW Roam PIN N IgMe6Maks amkosma(elel Hugh 0eeeeelellen. En eppeyenreriness halm TEE *7100(0410 TEE 10.3001200 tsfl *714444/6 M 117061.0410 t 010.10(1410 Pa 1M301.441 Fur 0/0.]01$410 ree 070 304411 /St Im01411p ra I*101.OM1 Oar %Sow TernrearnormItIweetieminEmpInsen„.. an rice l*gna,a$nee Cerre&IIMMMe.4 Itira bin% eta( MWI90yq. ,^ WATER DEPARTMENT APPROVAI4 Ambulance Service Name: PO/LY..ktL ktekla s S Ambulance 'Service 'Address: t,(1M to . City: G( State V° Zip Code: gOroSY Phone Number; nib C IC13`/,jr THIS SECTION FOR WATER DEPARTMENT USE ONLY What Is the water source? (Please circle one) Regulated Public Water System or Unregulated Water System REGULATED PUBLIC WATER: tunyotaewt Community Water System Date Connected to Source: 3'-1 to - I Z Name of Source: J ur Official's Signature: AlC'1.1.d ., J2L/ (r Date: II- 3 - mZ I Title: wp4Pjs, £ SaLJtA) Itentucta rtwjpltone Number: d'14 3 SO 1$ lb Non -Community Water System PNSIDN: PLEASE ATTACH APPROVAL LETTER PROM STATE ASSIGNED BY DISTRICT ENGINEER UNREGULATED WATER SYSTEM: Depth of Well What type ofcauinuous treatment will be provided? Hmdwhere will quarterly bacteriological samples be submitted? Who will be testing chlorine residual and fogging results when establishment is open? PLEASE ATTACH WRITTEN COMPLIANCE PLAN Weld County Health Dept. Water Program Manager Signature: Date: Title: Phone Number: ( ) Please Remit to: Weld County Deportment of Publk Health at Environment Attn: Environmental Health Services 1555 N. 176 Avenue Greeley, CO $0631 Phone(970)304-6415 Fax (970)304-6411 Page 13 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1656 North 17" Avenue Greeley, CO 80631 welx www.weIdhealth.o(e NMMM.*iletadel fuabnaMacaaitl IIWlMbaad lode, c.me.WMbry EMn.n•y Pointedness VMI Mewls Wang e.Ww. 1141.1,.*ebMW aalq./.1M. Tdce70.30.NN T*IflhI1M7e TdENae04e4N Va:fnUWOee rdr M0.a01M30 Fu 010204,4412 Pax lS00MMN fu emaNM11 fu 970,149162 fu Mea0UIN MrMfwr ne.aw..OlMIS.mmllsnwnx nw.u00b bmbSr*MowyfluW nip ee bit* MM FemYwpFby. LOCAL ZONING DEPARTMENT APPROVAL Please complete the following Informndon and have your local zoning office representative complete the section indicated. nee the form is completed, submit to the address stated below. Arnbuloacc Service Name: 1Caen-) JAL).€MS Ambulance Service Address; City: C Are -40 '\, StateCa Zip Code: ?O' 37 Phone Number : 97a) 6DY- /35'3 Tax l.D. Number: THIS SECTION FOR ZONING DEPARTMENT USE ONLY Check any that apply: $ The above named establishment meta the requirements for Zoning Department approval without bother action by establishment. o The above named establishment does not meet the requirements for Zoning Deportment approval. O Please see attached letter. Comments: Zoning Inspector Name (please prinp: R-(�SIlte P LM4l4 --ICE— Zoning Inspector Signature: Date: I INF— Local Jurisdiction: L(iY OP. �1-e( Phone Number:pa ) ..W). -°f2.--1-49 Please Remit to: Weld County Deportment of Public Health & Environment Attnt Euvirouatenial Henith Services 1555 N. 17t Avenue Greeley, CO 30631 Phone (970) 304-6415 Fax (970)304-6411 Official's Signature: SANITARY SEWER; Page 14 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1556 North 17" Avenue Greeley, CO 80031 Wex www.weldheaith.orp WIWMNft MMMa 1�„.W &C0aar N MMMNeale Cae.ealeaOes, rurandn,e eNta".a recoup asapaal.1 Fa1110104.4110 0. WNii Fl“ q 701MTit MN a NOICIM1IMI 1I 1 Fa paaa� Ux 17030/.1 M WING,.. Rats nth Oa PYMMa OININ.OManim*. Cale WOO Omit/ aeMNlk,/,YN eut Oaan IAA ea f;ay SEWAGE DISPOSALAPPROVAL FORM Ambulance Service Name: po�&44o-U l lS Phone Number: Qig62`(-f 5/3 Ambulance Service Address: (-51C JO 0 City: and -LL State el Zip Code: CP:343 Type of System: Sanitary Sewer or Individual Sewage Disposal System(ISDS) (MUST COMPLETE BACK OF FORM) THIS SECTION FOR SEWAGE DISPOSAL OFFICALS ONLY Sanitation District: 0 aJJj yi to v Pad Installation Date: 3 -16 - / System Official (please print): . I)Dr; 5 R, ,t. Al Title td da SAailtlz 4-1r/t.ulcn..- (aa SLAP Date: ii - g -ia THIS SECTION FOR WELD COUNTY HEALTH OFFICIALS ONLY INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS): Permit Name: Permit Number: Is system sized correctly for intended use: Official's Signature: Yes No Title Date: Please Remit to: Weld County Department of Public Health & Environment Attn: Environmental Health Services 1555 N. 17rs Avenue Greeley, CO 80631 Phone (970) 304.6415 Fax (970) 304-6411 Page 2 Sewage Disposal Approval Form O N r N toj Cr CMo4P47 S U° z El::e4 s4 awn or)F ad ‘..co. o44 oA W ��w E -40w kilm <c gel DY I.to) Wd uci, Eimpi i.4O ,1 PERMIT NO: 12020/98 BUILDING ADDRESS: 6906 1OTh STREET O ADDRESS: 2315 E. HARMONY ROAD, SUITE 200, FORT COLLINS, CO 80528 USE ZONING: C -H USE OF BUILDING: EMERGENCY CLINIC IBC OCCUPANCY: B NEW CONFORMING USE NEW CONFORMING STRUCTURE 'O • a•fl • O u o dU a .a _ g) V A O 0 o ti d • W ut i Q • v Pa gcit A0 to .2�. L 4.4 b0W v •a' 4- qq e�7 N •0 tz o Q -' 0 4 u w W A a y '4 tl .sn ) t • 4-• pL aO CI9' 4 O ✓ O 4- .9 01 • 4' 4.4 16• .5 pD •-• 7 a 7 Q u _ °u o .0 • H id IQ o ao M V t 1/ C .a = F w F Poudre Valley Hospital EMS Mutual Ad Agreemnts with the following ager : Legal Name Of Agency Level of Care ALSIBLS/CCT I 1. Poudre Fire Authority BLS 2.Glacierview Fire Protection District (GLV QRT) BLS 3. Larimer County Search and Rescue (LCSAR) BLS 4. Livermore Fire Protection District (LVQRT) _--- ..----- --- BLS" BLS 5. Poudre Canyon Fire Protection District (LPCQRT & UPCQRT) 6. Platte River Power Authority (PRPA) BLS BLS 7. Red Feather Lakes Fire Protection District (RFLQRT) 8. Wellington Fire Protection District (WELLQRT) BLS 9. Rist Canyon Fire Protection District (RCQRT) BLS 10. Poudre Valley EMT Reserves (PVH volunteer EMTs) 11. Thompson Valley EMS (WAS) BLS ALS 12. Weld County Ambulance Service (WCAS) ALS 13. Cheyenne American Medical Response (AMR) 14. Medevac Greeley I service) A ALS ALS/CCT F " agency has a certified Paramedic functioning as an EMT -1 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number TEMS Year of Manufacture 1992 Make GMC Model Suburban VIN number 1GKFKl6K5NJ72R454 Color Scheme_ Black Colorado State License Number 104 UGR Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Comments Engine ./ Transmission Wheels & Tires 7 Steering / Alignment / Suspension / Brakes / I -land brake Lights Electrical system / Vehicle and patient compartment heater and cooling system Glass Exhaust system / Fuel System Body & sheet metal / Other comments / The undersigned, professing to be a motor vehicle mechanic has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title Cd td .11.111/L:j r r: 1 rnl ' Company Name Date Address Telephone ?� - 'Feu. - .Y C -C;:' Rev: II2no6 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med I Year of Manufacture 2003 Make Ford Model E-450 Wheeled Coach VIN number I FDXE45F43HB28716 Color Scheme_White/Orange Colorado State License Number 091 UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine f Transmission Wheels & Tires Steering Alignment / Suspension / Brakes 7 Hand brake l Lights / Electrical system / Vehicle and patient compartment heater and cooling system / Glass l Exhaust system / Fuel System Body & sheet metal Other comments f le undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. -1fi�li, «L;V- Mechanic's Signature Title LI/O Company Name (1411 — Date Address Telephone Rev: 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 2 Year of Manufacture 2006 Make Ford Model Wheeled Coach Crusader_ VIN number 1FDSS34P96H820607 Color Scheme_ White and Green Colorado State License Number 087UGR Expiration Date 5/31/2013__ Evaluation Check List Item Acceptable Not Acceptable Comments Engine 7. Transmission / Wheels & Tires/ Steering Alignment Suspension Brakes / Hand brake Lights 7 Electrical system / Vehicle and patient compartment heater and cooling system Glass .."- Exhaust system Fuel System / Body & sheet metal / Other comments / The undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title Company Name .s-b/Cti l l r y r C././Ii,�> C� Date Address Telephone Rev: 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 4 Year of Manufacture 2003 Make Ford Model Wheeled Coach E-450 Amb_ VIN number 1 FDXE45FX31-IA31598 Color Scheme_White/Orange Colorado State License Number 092 UGR Expiration Date 5/3 I /2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires Steering / --_ Alignment / Suspension Brakes / — — Hand brake Lights Electrical system / Vehicle and patient compartment heater and cooling system Glass / Exhaust system / Fuel System Body & sheet metal / Other comments ... undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. („ed".4A:., Mechanic's Signature Title Dat it Company Name ,J3!', l/1(2)e j •I 7,//;x.1, 6• 9'//' 2 /'; >-, Address Telephone )C Rev: 1120O6 Larimer County Department of Health R. Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Make Ford Model Wheeled Coach E-450 VIN number IFDXf;4SI'26DA21099 Color Scheme_White/Orange Colorado State License Number 103 UGIZ Unit Number Merl 6 Year of Manufacture 2006 Evaluation Check List Expiration Date 5/31/2013. Item Acceptable Not Acceptable Comments Engine Transmission Wheels & Tires / Steering Alignment / Suspension / Brakes / Hand brake Lights /- Electrical system / Vehicle and patient compartment heater and cooling system / Glass Exhaust system Fuel System / Body & sheet metal i Other comments The undersigned. nrofessinc to be a motor vehicle mechanic. has of this date_ evaluated the +nechaniral ennriitinn ni the uienrifiefI emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee futnrq slate of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature r Company Name Address Title (b(? 9- (11 Date y4Cf 5. Lctlrgc Telephone Rev. 112OO6 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 9 Year of Manufacture 1999 Make Ford Model Wheeled Coach E-450 VIN number IFDWE30FSXHA26893 Color Scheme White/Orange Colorado State License Number 098 UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires / Steering 7 Alignment / Suspension / Brakes I -land brake e/ Lights / Electrical system / Vehicle and patient compartment heater and cooling system Glass / Exhaust system / Fuel System / Body & sheet metal / Other comments ie undersigned, professing to be a motor vehicle mechanic has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. fechr; Mechanic's Signature Title \, 4( i 7_1 Company Name Address GO" / f Date 1J'Gy 5 (4.1 e Er Cclliw) to 971.-1- 6 -.5'.)-ie: Telephone Rev. 112.006 J_>-rV Company Name Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Make_Ford Model Color Scheme Colorado State License Number Unit Number Med II Year of Manufacture 2005 Wheeled Coach E-450 Amb VIN number IFDXE45P85HA15380 White and Green 090UGR Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Comments Engine % Transmission Wheels & Tires / Steering l Alignment Suspension / Brakes / I -land brake 7 Lights / Electrical system / Vehicle and patient compartment heater and cooling system Glass Exhaust system / Fuel System / Body & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic has of this date, evaluated the mechanical condition of the rdentrflet emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. L/ eh car,` Mechanic's Signature Title Date H81 LutIri <v I I l t-tl' Co FO 1 I `,; %( -L- - YI 1 Address Telephone Rev. 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification _ Unit Number Med 12 Year of Manufacture 2008 Mnke_Ford Model F-350 XLT Frazer type I._._ VIN number 1 FDWF36R38EB25617 Color Scheme White and Green Colorado Slate License Number 099UGR _ Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Engine Transmission Comments Wheels & Tires Steering Alignment / Suspension Brakes Hand brake Lights Electrical system Vehicle and patient compartment heater and cooling system Glass Exhaust system Fuel System l Body & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Company Name Title Date (,)71 ( l hr..: ) C' Fr (ail]. I -I ) �L' �� t - Address Telephone Rev: 112006 l_arimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 14 Year of Manufacture 2008 Make Ford, Model F-350 XLT Frazer Type I VIN number I FDWF36R58EB25618 Color Scheme White and Green Colorado State License Number 100OGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires / Steering Alignment / Suspension / Brakes / Hand brake / Lights / Electrical system / Vehicle and patient compartment heater and cooling system Glass / Exhaust system / Fuel System Body & sheet metal Other comments The undersigned, professing to he a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title ter••, y Company Name }�1 Address Date Telephone LI) !)--- Rev I 1200 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 15 Year of Manufacture 2008 Make Ford! Model F-350 XLT Frazer Type I VIN number _I FDWF36R78EB25619 Color Scheme White and Green Colorado State License Number 101UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires % Steering 7 Alignment / Suspension / Brakes / Hand brake / Lights / Electrical system Vehicle and patient compartment heater and cooling system / Glass / Exhaust system Fuel System Body & sheet metal 7 Other comments 1 he undersigned, professing to be a motor vehicle mechanic, has of Ibis date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title �XvY (id dry. h / I"7 Company Name vAI ( ; u* 1 Rat Date `%/G - 7y(,, ,A't-ice Address Telephone Rev 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 16 Year of Manufacture 2008 Make Ford Model 1-350 XLT Frazer Type I VIN number I FDWF36R68EDI3130 Color Scheme White and Green Colorado State License Number 093UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission 7 Wheels & Tires / Steering Alignment 7 Suspension / Brakes Hand brake 7 Lights / Electrical system Vehicle and patient compartment heater and cooling system 7 Glass / Exhaust system Fuel System Body & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic has of this date, evahialed the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Pm, v. Company Name Tl- , Title ttYtii 1....>1)/ ( 0 Date Address Telephone 7G - .?:i: - Rev 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 17 Year of Manufacture 2008 Make Ford Model F-350 XLT Frazer Type I VIN number 1FDWF36RX8ED13129 Color Scheme White and Green Colorado State License Number 094UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires 7 Steering 7 Alignment / Suspension Brakes I -land brake i Lights Electrical system Vehicle and patient compartment heater and cooling system Glass 7 Exhaust system 7 Fuel System Body & sheet metal Other comments e undersigned, professing to be a motor vehicle mechanic has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature ;3 i.L� Y) ) 7pu Y ✓ Company Name cky1.- c V� Title Cvl1r7�' F, 019-91f 3-- Dat Address Telephone - — ,' vTc 7 Rev: 112006 Date of Certification Make ford_ Model F-350 XLT 4X4 Frazer Type 1 VIN number 1 EDWX37R38ED 1313 I _ Color Scheme White and Green Colorado State License Number 095UGR Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Unit Number Med 18 Year of Manufacture 2008 Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Comments Engine Transmission Wheels & Tires / Steering •/ Alignment Suspension / Brakes / Hand brake Lights / Electrical system Vehicle and patient compartment heater and cooling system / Glass Exhaust system Fuel System Body & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. („, Mechanic's Signature Title Lcl�fy� Fri— t!ul��cs Lc � , • zit r) )��:; Company Name (0(iel)--9 Date Address Telephone - )-7 _se [i, Rev: 112006 Date of Certification Make_Ford Model F-350 XLT Frazer Type I VIN number I FDWF36R49EA60827 Color Scheme White and Green Colorado State License Number 102UGR Expiration Date 5/3I/2013 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Unit Number Med 19 Year of Manufacture 2009 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission / Wheels & Tires Steering / Alignment Suspension / Brakes / Rand brake Lights / Electrical system / Vehicle and patient compartment heater and cooling system / Glass / Exhaust system Fuel System / Body & sheet metal / Other comments The undersigned, protessmg to be a motor vehicle mechamc, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature } rGellt' J Company Name Title CD, 1/1 -- Date H8L,:f - Lsijecle iT /cl it qtr `/1L 2 r: - .N'i )G' Address Telephone Rev: 112006 Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Make Ford Model F-450 XLT 4X4 Frazer Type t VIN number I FDAF4HR7AEA90I77 Color Scheme White and Green Colorado State License Number 089 UGR Expiration Date 5/31/2013 Unit Number Med 20 Year of Manufacture 2010 Evaluation Check List Item Acceptable Not Acceptable Comments Engine Transmission Wheels & Tires / Steering Alignment V Suspension 7 Brakes ./ Hand brake / Lights / Electrical system / Vehicle and patient compartment heater and cooling system / Glass , Exhaust system V Fuel System / Body & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title Cc.l.lr1a PM YJjiv.1 Company Name ,\% (0 Date Address Telephone Rev: 112006 Date of Certification Make Ford Model F-450 XLT 4X4 Frazer Type l VIN number IFDWF3GR3AEB3R114 Color Scheme White and Green Colorado State License Number 096 UGR Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Unit Number Med 21 Year of Manufacture 2010 Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Comments Engine Transmission Wheels & Tires Steering Alignment / Suspension Brakes Hand brake / Lights Electrical system / Vehicle and patient compartment heater and cooling system / Glass Exhaust system Fuel System / Body & sheet metal Other comments The undersigned, professing to he a motor vehicle mechanic has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond ' mechanic's control. Mechanic's Signature '}'.- act I't h3,ry l cc..�Y Company Name Title �ultry Fr fini PIS l r, (61 I lbkr Date Address Telephone Rev: 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 22 Year of Manufacture 2011 Make Dodge Model Dodge Ram 350 Type I VIN number 3D6WC'4ELXRG574309 Color Scheme White and Green Colorado State License Number 088 UGR Expiration Date 5/31/2013 Evaluation Check List Item Acceptable Not Acceptable Comments Engine /..-- Transmission / Wheels & Tires Steering 7 Alignment Suspension Brakes ,/ Hand brake / Lights / Electrical system / Vehicle and patient compartment heater and cooling system Glass 7 Exhaust system 7 Fuel System / Body & sheet metal / Other comments The undersigned, professing to be a motor vehicle mechanic has of this riare evaluated the mechanical Condit' urn e ii ei emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee futurF state of the emergency vehicle due to conditions beyond mechanic's conk nl. Mechanic's Signature Company Name Title FT (a Date t0 (I -31D - Address Telephone Rev! I12006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification AI- /0 - 12 Unit Number Med 23 Make Mercedes Model Mercedes Type III Amb _ Color Scheme Colorado State License Number 116 UGR White and Green Year of Manufacture 2012 VIN number WDAPF3CC9C9504702 Evaluation Check List Expiration Date 5/31/2013 Item Acceptable Not Acceptable Comments Engine X Transmission y Wheels & Tires y GCe( p 01 add e /9 t_r Steering y Alignment _ m 'c. Suspension X Brakes Hand brake I X Lights EI yiJ 4C FALL_�e, - Electrical system '( Vehicle and patient compartment heater and cooling system A Glass X Exhaust system )< Fuel System Body & sheet metal x Other comments 11 Ile. 40 fel511ait F 511"x? - The undersigned, professing to be a motor vehicle mechanic has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the mergency vehicle due to conditions beyond mechanic's control. Dual e r echanic's Signature Title iO-►t- 12• Date g-dl'≥9eovi l%L4oyCam Seg Q�Jersrt. 4/F SZ >{91'-evyp. Company Name Address Telephone Rev112006 OP ID: JD AFRO' 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 OF PROPERTY INSURANCE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AGENCY PINE 970-482-7747 COMPANY Brown & Brown Inc LLu�NPD Great Northern Insurance Co. 4532 Boardwalk Dr, Suite 200 15 Mountain View Road Fort Collins, CO 80525 Warren, NJ 07059 Tyler B. Allen EVIDENCE OF PROPERTY INSURANCE DATE IMMIDOIYYYYI 05/14/2012 FAX S70-484-4165 EMAIL (Alt No). ADDRESS: CODE: 15243 1 SUB CODE: AGENCY PVHEA-1 CUSTOMER ID A; INSURED Poudre Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528-8620 LOAN NUMBER POLICY NUMBER 35833405 EFFECTIVE DATE 05/01112 EXPIRATION DATE 05/01113 THIS REPLACES PRIOR EVIDENCE DATED: CONTINUED UNTIL I I TERMINATED IF CHECKED PROPERTY INFORMATION LOCATION/DESCRIPTION Per schedule of locations on file 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. COVERAGE INFORMATION COVERAGE I PERILS I FORMS Blanket Building, BPP /Special Fornt/Repl Coat LOSS LIMIT BI/EE AMOUNT OF INSURANCE DEDUCTIBLE 550000000 Included 25,000.00 24.00 REMARKS (Including Special Conditions) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ADDITIONAL INTEREST NAME AND ADDRESS Poudre Valley Health Systems 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528 LOAN M MORTGAGEE LOSS PAYEE _ ADDITIONAL INSURED r AUTHORIZED REPRESENTATIVE Watt -5v\ ACORD 27 (2008/07) © ACORD CORPORATION 1993.2006. All rights reserved. The ACORD name and logo are registered marks of ACORD A ORO- CERTIFICATE OF LIABILITY INSURANCE OP ID JD DATE(AMIIDDIYYYY) 05/14/12 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 pollcy(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 hi lieu of such endorsement(s). PRODUCER Brown & Brown Inc 4532 Boardwalk Dr, Suite 200 Fort Collins CO 80525 Phone:970-482-7747 Fax:970-484-4165 umRL NAME: PHONE FAX moat, En): (NC. No): .-_ ADDRESS: PRODO CUSTOMERER10 A: PVHEA-1 INSURER(S)AFFORDING COVERAGE NAICM INSURED Poudre Valley Health Care Inc 2315 E. Harmony Rd. Suite 200 Fort Collins CO 805'18-8620 INSURER A: travelers casualty and Surety 19038 INSURER II: Zurich Nam -icon Insurance co. 16535 INSURER C: The Hartford tsr. c Accident 70815 INSURER D: INSURER E : INSURER F CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TIIE 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, IHE INSURANCE AFFORDED BY IIIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES I IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �A my LTp TYPE OF INSURANCE DM S� POLICY NUMBER ( MIDDI YV) (MINDD�M'WY) LIMITS GENERAL LIABIl1TY COMMERCIALGENERALLIABILITY HCAMS -MADE I I OCCUR EACH OCCURRENCE .VAMAL,EIV S HEN I Ell PREMISES (Ea occurrence) - - $ MED EX (Any one person) $ GEN'L PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ AGGREGATE LIMIT APPLIES PER. POLICY PRO- JECT I LOC PRODUCTS COMPIOP AGG S S B AUTOMOBILE X X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Auto PD BAP947490301 BAP947490301 05/01/12 05/01/12 05/01/13 05/01/12 COMBINED SINGLE LIMIT (Ea accident) jl,DDD, GGO BODILY INJURY (Per person) $ BODILY INJURY (PM aCdderll $ PROPERTY DAMAGE (Per deadens) $ Comp s $500 Ded Coll S $500 Ded UMBRELLA LIAR EXCESS LIAR — OCCUR CLAIMS -MADE EACH OCCURRENCE $ AlAiHEGA IE j DEDUCTIBLE RETENTION S X WORKERS COMPENSATION AND EMPLOYERS' UABIUTY Y H ANY PROPRIETOR/PARTNER/EXECUTIV4 OFFICER/MEMBER EXCLUDED? I N I A WC AILT TORY LIMITS LER EE E LEACH ACCIDENT . $ I (Mandatory In NHI II yes. under der DESCRIPTION OF OPERATIONS below EL. DISEASE- EA EMPLOYEE $ . E.LDISEASE. POLICY LIMIT $ A C Crime Volunteer Accident 104900205 34SR845295 03/10/10 07/01/11 03/10/13 07/01/12 Empl Dish $250,000 Medical $10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ARscl ACORD 101, Additional Remark. Schedule, R more space Is required) For info only CANCELLATIO PVHHEAL Poudre Valley Health Systems 2315 E. Harmony Rd #200 )Ft. Collins CO 80528 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE Wit L BE DELIVERED IN ACCORDANCE WITH THE POLICY PROWSIONS. AUTHORIZED REPRESENTATIVE --Vac ACORD 25 (2009/09) 988.2009 ACO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • PVHEA ACORD,u CERTIFICATE OF LIABILITY INSURANCE DATE (M7/03/2012 W) 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 POUCIES 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(les) 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 Flood & Peterson Ins., Inc. P. O. Box 578 Greeley, CO 80632 CONTACT Nikki Mosbruek er NAME: 970 506-6823 PHONE FAN AIC No Ex": 970 266-7123 I IAJc�Nol: ADDRES nikki.moshrucker@tloodandpeterson.com -- --_-- -- roHYDOCEu CUSTOMER ID s 970 356.0123 INSURER(S) AFFORDING COVERAGE NAIC A INSURED Poudre Valley Health Care, Inc. dba Poudre Valley Health System 2315 E Harmony Road, Suite 200 Fort Collins, CO 80528.8620 INSURER A: COOK Companies INSURER e: Safety National Casualty Compan INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES 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 REQU REMENT, 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. iilSR LTR TYPE OF INSURANCE ADDI. UBR 0 POLICYNUMBER POLICYEFF MMIDDIYYYY) POLICY EXP (MMNONYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X OCCUR ,NSR HCC0008522 Retro Date: 5/1/1994 04/0112012 04/01/2013 EACH OCCURRENCE DAMAGE TO -RENTED_ PREMISES (Ea occurrence) $1L000r000 $500,000 $5,000 _ i X XI CLAIMS -MADE Malpractice MEDEXP (Any one person) PERSONAL&ABU INJURY GENERAL AGGREGATE $1,000X00 _ Liability $3,000,900 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY JECT fl LOC PRODUCTS -COMPIOPAGG $1,000,000 $ AUTOMOBILE _ LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS I TIRED AUTOS NON OWNED AUTOS COMBINED SINGLE LIMIT IFS accident) $ BODILY INJURY 'Per person) $ BODILY INJURY'Pel accident) $ PROPERTY DAMAGE (Per al -orient)$ $ $ A X UMBRELLA LIAR EXCESS LIAR X X OCCUR CLAIMS -MADE UCC0009293 4/01/2012 04/01/2013 EACH OCCURRENCE $15 000 000 AGGREGATE s15,000,000 DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANY OFFICER/MEMBER XCI.UDED?ECUTNEY (Mandatoryin NH) II yes describe under DESCRIPTION OF OPERATIONS NIA SP4043886 Excess Coverage 04/01/2012 04101/201;))wr BTATu- IDDI TORY ICCIDorm ER E. L. EACH ACCIDENT $1,000,000 N EL. DISEASE - EA EMPLOYEE $1,000,000 below EL -DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD101, Additional Remarks Schedule, II more spacers required) CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION Sample Certificate SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1088-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD DXS #S714206/M684901 This page has been left blank intentionally. POLICY NUMBER: COMMERCIAL AUTO CA 99 60 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE ADDED LIMITS This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Poudre Valley Health Care Inc. Endorsement Effective Date: 0510 I:2012 SCHEDULE Descri tion Of Covered "Auto" Each "Accident" Limit Additional Premium Per Schedule of Covered Autos $ Per Schedule of Covered Autos $ INCLUDED $ $ $ $ Information re uired to com lete this Schedule if not shown above, will be shown in the Declarations. The Physical Damage Coverage section is amended as follows: The sub -limit in Paragraph C.2. of the Limit Of Insur- ance Provision is in addition to the Each "Accident" Limit shown in the Schedule of this endorsement. CA 99 60 0310 © Insurance Services Office, Inc., 2009 Page 1 of 1 Wolters Kluwer Financial Services I Uniform Forms" ZURICH Advisory notice to policyholders regarding the U.S. Treasury Department's Office of Foreign Assets Control ("OFAC') regulations No coverage is provided by this policyholder notice nor can it be construed to replace any provisions of your policy. You should read your policy and review your declarations page for complete Information on the coverages you are provided. This notice provides information concerning possible impact on your insurance coverage due to directives issued by the U.S. Treasury Department's Office of Foreign Assets Control ("OFAC"). Please read this Notice carefully. OFAC administers and enforces sanctions policy based on Presidential declarations of "national emergency". OFAC has identified and listed numerous: • Foreign agents; • Front organizations; • Terrorists; • Terrorist organizations; and • Narcotics traffickers; as "Specially Designated Nationals and Blocked Persons," This list can be located on the United States Treasury's web site - http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx. In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this insurance will be considered a blocked or frozen contract and all provisions of this insurance are immediately subject to OFAC restrictions. Wien an insurance policy is considered to be such a blocked or frozen contract, no payments or premium refunds may be made without authorization from OFAC. Other limitations on premiums and payments also apply. Includes copyrighted material of Insurance Services Office, Inc., with its permission. u -GU -1041a (3/11) Page 1 oft ZURICH COMMERCIAL INSURANCE COMMON POLICY DECLARATIONS Policy Number BAP 9474903-01 Named Insured and Mailing Address POUDRE VALLEY HEALTH CARE INC (SEE NAMED INSURED ENDT) 2315 E. HARMONY RD STE 200 FORT COLLINS CO 80528 Renewal of Number BAP 9474903-00 Producer and Mailing Address THOMPSON INSURANCE ENTERPRISES 3380 CHASTAIN MEADOWS PKWY NW STE 100 KENNESAW GA 30144-5881. Producer Code 01.087-000 Policy Period: Coverage begins 05-01-2012 at 12:01AM.; Coverage ends 05-01-2013 at 12:01AM. The name insured Is ❑ Individual Partnership ❑X Corporation ❑ Other: This insurance is provided by ore or more of the stock insurance companies which are members of the Zurich -American Insurance Goup. The company Thal provides coverage is designated on each Coverage Part Common Declarations. The company or companies providing his insurance may he referred loin this policy as "The Company". we, us, or our. The address of the companies of the Zurich -American Ireurance Goup are provided on the next page. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE(S): BUSINESS AUTOMOBILE issued by ZURICH AMERICAN INSURANCE COMPANY PREMIUM $ 110,297.00 THIS PREMIUM MAY BE SUBJECT TO AUDIT. This premium does not include Taxes and Surcharges. TOTAL S 110,297.00 Taxes and Surcharges TOTAL S The Form(s) and Endorsemenl(s) made a part of this policy at the time of issue are listed on the SCHEDULE of FORMS and ENDORSEMENTS. Countersigned this day of Authorized Representative THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART FORM(S), FORMS AND ENDORSEMENTS. IF ANY. ISSUED TO FORM A PMT THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. U -GU -D -310J1 (01/93) Page 1 oft Policy Number BAP 9474903-01 SCHEDULE OF FORMS AND ENDORSEMENTS ZURICH AMERICAN INSURANCE COMPANY Named Insured POUDRE VALLEY HEALTH CARE INC Effective Date: 05-01-12 12:01 A.M., Standard Time AgentName THOMPSON INSURANCE ENTERPRISES AgentNo. 01087-000 COMMON POLICY FORMS AND ENDORSEMENTS U -GU -D -310-A U -GU -619-A CW U -GU -319-F U -GU -621-A CW IL 00 17 IL 00 21 IL 01 69 IL 02 28 IL 00 03 01-93 COMMON POLICY DECLARATIONS 10-02 SCHEDULE OF FORMS AND ENDORSEMENTS 01-09 IMPORTANT NOTICE - TN WITNESS CLAUSE 10-02 SCHEDULE OF NAMED INSURED(S) 11-98 COMMON POLICY CONDITIONS 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDT 09-07 CO CHANGES -CONCEALMENT, MISREP. OR FRAUD 09-07 COLORADO CHANGES-CANC & NONRENEWAL 09-08 CALCULATION OF PREMIUM AUTOMOBILE FORMS AND ENDORSEMENTS CA 20 54 CA 23 84 CA 23 94 U -CA -41.1-C CW U -CA -548-A CW U -CA -D -600B CA 00 01 CA 01 13 CA 20 99 CA 21 50 CA 24 02 U -CA -816-A CW CA 20 02 CA 20 18 CA 20 48 CA 99 28 CA9960 10-01 EMPLOYEE HIRED AUTOS 01-06 EXCLUSION OF TERRORISM 03-06 SILICA/SILICA-RELATED EXCL FOR COVRD AU 04-09 PREMIUM AND REPORTS AGREEMENT COMPOSITE 10-06 SCHEDULE OF AUTO PHYSICAL DAMAGE DEDUCTT 06-10 BUSINESS AUTO DECLARATIONS 03-10 BUSINESS AUTO COVERAGE FORM 01-11 COLORADO CHANGES 03-10 CO EMRG VEHCL VOL FIREFCHTRS/WRKRS EXCLD 01-11 CO UM COVERAGE - BODILY INJURY 12-93 PUBLIC TRANSPORTATION AUTOS 03-10 AMENDMENT OF DECLARATIONS - ITEM 4 03-10 SOUND RECEIVING EQUIP COVG -FIRE, POLICE 12-93 PROFESSIONAL SERVICES NOT COVERED 02-99 DESIGNATED INSURED 03-1.0 STATED AMOUNT INSURANCE 03-10 AUDIO, VISUAL AND DATA ELECTRONIC EQUIP U -GU -619-A CW (10/02) Important Notice — In Witness Clause ZURICH In return for the payment of premium, and subject to the terms of this policy, coverage Is provided as stated in this policy. IN WITNESS WHEREOF, this Company has executed and attested these presents and, where required by law, has caused this policy to be countersigned by Its duly Authorized Representative(s). -lieu b.u,u1f President Corporate Secretary QUESTIONS ABOUT YOUR INSURANCE? Your agent or broker is best equipped to provide Information about your insurance. Should you require additional information or assistance in resolving a complaint, call or write to the following (please have your policy or claim number ready): Zurich in North America Customer Inquiry Center 1400 American Lane Schaumburg, Illinois 60196-1056 1-800-382-2150 (Business Hours: Sam - 4pm [CT]) Email: Into.source@zurIchna.com U-OU-3l 9-r (01109) Pagel ufl Poky Number SAP 947490341 SCHEDULE OF NAMED INSUREDS) ZURICH AMERICAN INSURANCE COMPANY Named Insured Agent Name POUDRE VALLEY HEALTH CARE INC THOMPSON INSURANCE ENTERPRISES Effective Date: 05-01-12 12:01 AM., Standard Time Agent No. 01087-000 NAMED INSURED POUDRE VALLEY HEALT❑ CARE INC POUDRE VALLEY HEALTH CARE, INC. A COLORADO NON-PROFIT CORP DBA: POUDRE VALLEY HOSPITAL DBA: POUDRE VALLEY HEALTH SYSTEM POUDRE VALLEY HOSPITAL FOUNDATION HARMONY VALLEY CONDOMINIUMS THE HARMONY AMBULATORY SURGERY CENTER, LLC HARMONY IMAGING CENTER, LLC POUDRE VALLEY RADIATION ONCOLOGY, LLC UNITED MEDICAL ALLIANCE, LLC PVHS/TIMBERLINE, LLC HARMONY CAMPUS MASTER ASSOCIATION MEDICAL CENTER OF THE ROCKIES, LLC MEDICAL CENTER OF THE ROCKIES FOUNDATION SURGICAL SPECIALIST OF THE ROCKIES FOXTRAIL FAMILY MEDICINE SNOW LAKE, LLC HERON LAKE, LLC NEUROLOGY ASSOCIATES OF NORTHERN COLORADO TWENTY THREE TREES POUDRE VALLEY MEDICAL GROUP, LLC GREELEY MEDICAL CLINIC, PC HEART CENTER OF THE ROCKIES POUDRE VALLEY MEDICAL FITNESS CHEYENNE MEDICAL SPECIALISTS LAKOTA LAKE LLC STAMPEDE PROPERTIES LLC HEALTH DISTRICT OF NORTHERN COLORADO U -GU -621-A CW (10/02) IL00171198 COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions A. Cancellation 1. The first Named Insured shown in the Declara- tions may cancel this policy by mailing or de- livering to us advance written notice of cancel- lation. 2. We may cancel this policy by mailing or deliv- ering to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancel- lation if we cancel for nonpayment of pre- mium; or h. 30 days before the effective date of cancel- lation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policyperiod will end on that date. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will he effective even if we have not made or offered a refund. 6. If notice is mailed, proof of mailing will be suf- ficient proof of notice. R. Changes This policy contains all the agreements between you and us concerning the insurance atlbrded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. C. Examination Of Your Rooks And Records We may examine and audit your books and records as they relate to this policy at any time during the policy period and up to three years afterward. D. Inspections And Surveys 1. We have the right to: a. Make inspections and surveys at anytime; IL 00 17 11 98 b. Give you reports on the conditions we find; and c. Recommend changes. 2. We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to in- surability and the premiums to he charged. We do not make safety inspections. We do not un- dertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not war- rant that conditions: a. Are safe or healthf l; or h. Comply with laws, regulations, codes or standards. 3. Paragraphs 1. and 2. of this condition apply not only to us, but also to any rating, advisory, rate service or similar organization which makes in- surance inspections, surveys, reports or recom- mendations. 4. Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recommen- dations we may make relative to certification, tinder state or municipal statutes, ordinances or regulations, of boilers, pressure vessels or ele- vators. E. Premiums The first Named Insured shown in the Declarations: I. Is responsible for the payment of all premiums; and 2. Will be the payee for any return premiums we Pay. P. Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named insured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representa- tive. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 O IL 00 2109 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form) This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY 1. The insurance does not apply: A. Under any Liability Coverage, to "bodily injury" or "property damage": (1) With respect to which an 'insured" under the policy is also an insured under a nu- clear energy liability policy issued by Nu- clear Energy Liability Insurance Association, Mutual Atomic Energy Liability Underwrit- ers, Nuclear Insurance Association of Can- ada or any of their successors, or would be an insured under any such policy but for its termination upon exhaustion of its limit of li- ability; or (2) Resulting from the 'hazardous properties" of "nuclear material" and with respect to which (a) any person or organization is re- quired to maintain financial protection pur- suant to the Atomic Energy Act of 1954, or any law amendatory thereof, or (h) the in- sured" is, or had this policy not been issued would be, entitled to indemnity from the United States of America, or any agency thereof, under any agreement entered into by the United States of America, or any agency thereof, with any person or organi- zation. B. Under any Medical Payments coverage, to expenses Incurred with respect to 'bodily in- jury" resulting from the 'hazardous properties" of "nuclear material" and arising out of the op- eration of a "nuclear facility" by any person or organization. IL 0021 09 08 C. Under any Liability Coverage, to "bodily injury" or "property damage" resulting from 'hazardous properties" of "nuclear material", if: (1) The "nuclear material" (a) is at any "nuclear facility" owned by, or operated by or on be- half of, an 'insured" or (b) has been dis- charged or dispersed therefrom; (2) The "nuclear material" is contained In "spent fuel" or 'Waste" at any time possessed, han- dled, used, processed, stored, transported or disposed of, by or on behalf of an in- sured", or (3) The "bodily injury" or "property damage" arises out of the furnishing by an "insured" of services, materials, parts or equipment In connection with the planning, construction, rrointenance, operation or use of any "nu- clear facility", but if such facility Is located within the United States of America, its terri- tories or possessions or Canada, this ex- clusion (3) applies only to "property dam- age" to such "nuclear facility" and any properly thereat. 2. As used in this endorsement: "Hazardous properties" Includes radioactive, toxic or explosive properties. 'Nuclear material" means "source material", "special nuclear material" or 'by-product material". © ISO Properties, Inc., 2007 Page 1 of 2 O 'Source material", "special nuclear material", and "by-product material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof. "Spent fuel" means any fuel element or fuel corm ponent, solid or liquid, which has been used or exposed to radiation in a "nuclear reactor". "Waste" means any waste material (a) containing "by-product material" other than the tailings or wastes produced by the extraction or concentra- tion of uranium or thorium from any ore processed primarily for its "source material" content, and (b) resulting from the operation by any person or or- ganization of any "nuclear facility" included under the first two paragraphs of the definition of "nu- clear facility". 'Nuclear facility" means: (a) Any "nuclear reactor"; (b) Any equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing "spent fuel", or (3) handling, processing or packaging 'Waste'; Page 2of2 (c) Any equipment or device used for the proc- essing, fabricating or alloying of "special nuclear material" if at any time the total amount of such material in the custody of the insured" at the premises where such equipment or device is located consists of or contains more than 25 grams of pluto- nium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; (d) Any structure, basin, excavation, premises or place prepared or used for the storage or disposal of 'Waste"; and includes the site on which any of the forego- ing is located, all operations conducted on such site and all premises used for such operations. 'Nuclear reactor" means any apparatus designed or used to sustain nuclear fission in a self- supporting chain reaction or to contain a critical mass of fissionable material. Property damage" includes all forms of radioactive contamination of properly. © ISO Properties, Inc., 2007 1L00210908 ❑ IL 01 69 09 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CHANGES - CONCEALMENT, MISREPRESENTATION OR FRAUD This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART - FARM PROPERTY -OTHER FARM PROVISIONS FORM -ADDITIONAL COVERAGES, CONDITIONS, DEFINITIONS FARM COVERAGE PART -LIVESTOCK COVERAGE FORM FARM COVERAGE PART —MOBILE AGRICULTURAL MACHINERY AND EQUIPMENT COVERAGE FORM The CONCEALMENT, MISREPRESENTATION OR FRAUD Condition is replaced by the following: CONCEALMENT, MISREPRESENTATION OR FRAUD We will not pay for any loss or damage in any case of: 1. Concealment or misrepresentation of a material fact; or 2. Fraud; committed by you or any other insured (Insured') at any titre and relating to coverage under this policy. IL01690907 © ISO Properties, Inc., 2006 Page 1 of 1 O IL 02 28 09 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CHANGES - CANCELLATION AND NONRENEWAL This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT -RELATED PRACTICES LIABILITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART FARM UMBRELLA LIABILITY POLICY LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraph 2. of the Cancellation Common Policy Condition is replaced by the following: 2. If this policy has been in effect for less than 60 days, we may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancella- tion if we cancel for nonpayment of pre- mium; or b. 30 days before the effective date of cancella- tion if we cancel for any other reason. B. The following is added to the Cancellation Com- mon Policy Condition: 7. Cancellation Of Poirdes In Effect For 60 Days Or More a If this policy has been in effect for 60 days or more, or is a renewal of a policy we is- sued, we may cancel this policy by mailing through first-class mall to the first Named Insured written notice of cancellation: (1) Including the actual reason, at least 10 days before the effective date of cancel- lation, If we cancel for nonpayment of premium; or (2) At least 45 days before the effective dale of cancellation If we cancel for any other reason. IL 02 28 09 07 C. We may only cancel this policy based on one or more of the following reasons: (1) Nonpayment of premium; (2) A false statement knowingly made by the insured on the application for insurance; or (3) A substantial change in the exposure or risk other than that indicated in the ap- plication and underwritten as of the ef- fective date of the policy unless the first Named Insured has notified us of the change and we accept such change. The following Is added and supersedes any other provision to the contrary: NONRENEWAL If we decide not to renew this policy, we will mail through first-class mail to the first Named Insured shown in the Declarations written notice of the nonrenewal at least 45 days before the expiration date, or its anniversary date if it is a policy written for a term of more than one year or with no fixed expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. 8 ISO Properties, Inc., 2006 Page 1 of 2 ❑ D. The following condition is added: INCREASE IN PREMIUM OR DECREASE IN COVERAGE VNe will not Increase the premium unilaterally or decrease the coverage benefits on renewal of this policy unless we mall through first-class mall writ- ten notice of our intention, Including the actual rea- son, to the first Named Insured's last mailing ad- dress known to us, at least 45 days before the ef- fective date. Page 2 of 2 Any decrease in coverage during the policy term must be based on one or more of the following reasons: 1. Nonpayment of premium; 2. A false statement knowingly made by the in- sured on the application for Insurance; or 3. A substantial change in the exposure or risk other than that indicated in the application and underwritten as of the effective date of the pol- icy unless the first Named Insured has notified us of the change and we accept such change. If notice is mailed, proof of mailing will be sufficient proof of notice. C) ISO Properties, Inc., 2006 IL02280907 ❑ IL 00 03 09 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALCULATION OF PREMIUM This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT -RELATED PRACTICES LIABILITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART The following is added: The premium shown in the Declarations was com- puted based on rates in effect at the time the policy was issued. On each renewal, continuation, or anni- versary of the effective date of this policy, we will compute the premium in accordance with our rates and rules then in effect. IL 00 03 09 08 © ISO Properties, Inc., 2W7 Page 1 of 1 ❑ COMMERCIAL AUTO CA 20541001 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYEE HIRED AUTOS This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. A. Changes In Liability Coverage The following is added to the Who is An Insured Provision: An 'employee" of yours Is an 'Insured" while oper- ating an 'auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. B. Changes In General Conditions Paragraph 5.b. of the Other Insurance Condition in the Business Auto, Business Auto Physical Damage and Garage Coverage Forms, Paragraph 5.d. of the Other Insurance - Primary And Excess Insurance Provisions Condition in the Truckers Coverage Form and Paragraph 5.f. of the Other Insurance - Primary And Excess Instrance ProN- Mons in the Motor Carrier Coverage Form are re- placed by the following: CA 20 54 10 01 For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: 1. Any covered "auto" you lease, hire, rent or borrow; and 2. Any covered 'auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto"that is leased, hired, rented or borrowed with a driver is not a covered 'auto". ISO Properties, Inc., 2000 Page 1 of 1 COMMERCIAL AUTO CA 23 84 0106 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION OF TERRORISM This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM SINGLE INTEREST AUTOMOBILE PHYSICAL DAMAGE INSURANCE POLICY TRUCKERS COVERAGE FORM With respect to coverage provided by this endorse- ment, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following definitions are added and apply under this endorsement wherever the term terror- ism, or the phrase any injury, damage, loss or ex- pense, are enclosed in quotation marks: 1. "Terrorism" means activities against persons, organizations or property of any nature: a. That involve the following or preparation for the following: (1) Use or threat of force or violence; or (2) Commission or threat of a dangerous act; or (3) Commission or threat of an act that interferes with or disrupts an electronic, communication, information, or me- chanical system; and b. Wien one or both of the following applies: (1) The effect is to intimidate or coerce a government or the civilian population or any segment thereof, or to disrupt any segment of the econony; or (2) It appears that the intent is to intimidate or coerce a government, or to further political, ideological, religious, social or economic objectives or to express (or express opposition to) a philosophy or ideology. CA238401 06 2. "My injury, damage, loss or expense" means any injury, damage, loss or expense covered under any Coverage Form or Policy to which this endorsement is applicable, and includes but is not limited to "bodily injury", 'property damage", "personal injury", "personal and ad- vertising injury", 'loss", loss of use, rental reim- bursement after 'loss" or "covered pollution cost or expense', as may be defined under this Coverage Form, Policy or any applicable en- dorsement. B. Except with respect to Physical Damage Coverage, Trailer Interchange Coverage, Garagekeepers Coverage, Garagekeepers Coverage — Customers' Sound Receiving Equipment or the Single Interest Automobile Physical Damage Insurance Policy, the following exclusion is added: EXCLUSION OF TERRORISM We will not pay for "any injury, damage, loss or expense" caused directly or indirectly by "terror- ism", including action in hindering or defending against an actual or expected incident of 'terror- ism". "My injury, damage, loss or expense" is ex- cluded regardless of any other cause or event that contributes concurrently or in any sequence to such injury, damage, loss or expense. But this ex- clusion apples only when one or more of the fol- lowing are attributed to an Inddent of 'terrorism": 1. The "terrorism" is carried out by means of the dispersal or application of radioactive material, or through the use of a nuclear weapon or de- vice that Involves or produces a nuclear reac- tion, nuclear radiation or radioactive contamina- tion; or ISO Properties, Inc., 2004 Page 1 of 3 O 2. Radioactive material is released, and it appears that one purpose of the "terrorism" was to re- lease such material; or 3. The 'terrorism' Is carried out by means of the dispersal or application of pathogenic or poi- sonous biological or chemical materials; or 4. Pathogenic or poisonous biological or chemical materials are released, and it appears that one purpose of the 'terrorism" was to release such materials; or 5. The total of insured damage to all types of property exceeds $25,000,000. In determining whether the $25,000,000 threshold is exceeded, we will include all insured damage sustained by property of all persons and entitles affected by the "terrorism"and business interruption losses sustained by owners or occupants of the dam- aged property. For the purpose of this provi- sion, insured damage means damage that is covered by any insurance plus damage that would be covered by any insurance but for the application of any terrorism exclusions; or 6. Fifty or more persons sustain death or serious physical injury. For the purposes of this provi- sion, serious physical injury means: a. Physical Injury that involves a substantial risk of death; or b. Protracted and obvious physical disfigure- ment; or c. Protracted loss of or impairment of the function of a bodily member or organ. Multiple inddents of "terrorism" which occur within a 72 -hour period and appear to be carried out in concert or to have a related purpose or common leadership will be deemed to be one incident, for the purpose of determining whether the thresholds in Paragraphs B.5. and B.6. are exceeded. With respect to this Exclusion, Paragraphs B.5. and 8.6. describe the thresholds used to measure the magnitude of an incident of 'terrorism' and the circumstances in which the threshold will apply, for the purpose of determining whether this Exclu- sion will apply to that incident. When the Exclusion applies to an incident of "terrorism", there is no coverage under this Coverage Form, Policy or any applicable endorsement. Page 2 of 3 C. With respect to Physical Damage Coverage, Trailer Interchange Coverage, Garagekeepers Coverage, Caragekeepers Coverage — Customers' Sound Receiving Equipment or the Single Interest Auto- mobile Physical Damage Insurance Policy, the fol- lowing exclusion Is added: EXCLUSION OF TERRORISM We will not pay for any loss", loss of use or rental reimbursement after loss" caused directly or Indi- rectly by 'terrorism", including action in hindering or defending against an actual or expected inci- dent of "terrorism". But this exclusion apples only when one or more of the folowing are attributed to an Inddent of'terrorism't 1. The 'terrorism" is carried out by means of the dispersal or application of radioactive material, or through the use of a nuclear weapon or de- vice that involves or produces a nuclear reac- tion, nuclear radiation or radioactive contamina- tion; or 2. Radioactive material Is released, and it appears that one purpose of the 'terrorism" was to re- lease such material; or 3. The 'terrorism" is carried out by means of the dispersal or application of pathogenic or poi- sonous biological or chemical materials; or 4. Pathogenic or poisonous biological or chemical materials are released, and It appears that one purpose of the terrorism" was to release such materials; or 5. The total of insured damage to all types of property exceeds $25,000,000. In determining whether the $25,000,000 threshold is exceeded, we will Include all insured damage sustained by property of all persons and entities affected by the 'terrorism"and business Interruption losses sustained by owners or occupants of the dam- aged property. For the purpose of this provi- sion, insured damage means damage that is covered by any Insurance plus damage that would be covered by any insurance but for the application of any terrorism exclusions. Multiple incidents of "terrorism" which occur within a 72 -hour period and appear to be carried out in concert or to have a related purpose or common leadership will be deemed to be one Incident, for the purpose of determining whether the threshold in Paragraph C.S. is exceeded. CO ISO Properties, Inc., 2001 CA23840106 O With respect to this Exclusion, Paragraph C.5. de- scribes the threshold used to measure the magni- tude of an incident of "terrorism` and the circum- stances in which the threshold will apply, for the purpose of determining whether this Exclusion will apply to that incident. When the Exclusion applies to an incident of "terrorism", there is no coverage under this Coverage Form, Policy or any applica- ble endorsement. CA23840106 D. In the event of any incident of "terrorism" that is not subject to the Exclusion In Paragraphs B. or C., coverage does not apply to "any injury, dam- age, loss or expense" that is otherwise excluded under this Coverage Form, Policy or any applica- ble endorsement. O ISO Properties, Inc., 2034 Page3of3 El COMMERCIAL AUTO CA 23 94 03 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SILICA OR SILICA -RELATED DUST EXCLUSION FOR COVERED AUTOS EXPOSURE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM Wth respect to coverage provided by this endorserent, the provisions of the Coverage Form apply unless modi- fied by the endorsement. A The following exclusion is added to Paragraph B. Exclusions of Section II —Liability Coverage in the Business Auto, Motor Carrier and Truckers Cover- age Forms and for 'Garage Operations" —Covered 'Autos" In the Garage Coverage Form: SILICA OR SILICA -RELATED DUST EXCLUSION FOR COVERED AUTOS EXPOSURE This insurance does not apply to: 1. "Bodily injury" arising, in whole or in part, out of the actual, alleged, threatened or suspected inhalation of, or ingestion of, "silica" or "silica - related dust". 2. "Property damage" arising, in whole or In part, out of the actual, alleged, threatened or sus- pected contact with, exposure to, existence of, or presence of, "silica" or "silica -related dust". CA 23 9403 06 3. My loss, cost or expense arising, in whole or in part, out of the abating, testing for, monitor- ing, cleaning up, removing, containing, treat- ing, detoxifying, neutralizing, remediating or disposing of, or in any way responding to or assessing the effects of, "silica" or "silica -related dust", by any 'Insured" or by any other person or entity. B. Addtional Definitions As used in this endorsement: 1. "Silica" means silicon dioxide (occurring In crystalline, amorphous and Impure forms), sil- ica particles, silica dust or silica compounds. 2. "Silica -related dust" means a mixture or combi- nation of silica and other dust or particles. © ISO Properties, Inc., 2005 Page 1 of 1 ❑ Premium and Reports Agreement Composite Rated Policies ZURICH THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. SCHEDULE Unit of Exposure Indicate your selection with an E. X per "auto" per "auto — power units only" Li per "other", as described below: per $100 "cost of hire" per $100 of "gross receipts" per 10,000 "miles" per 100 "miles" ,_ per $1,000 "payroll" Estimated Unit(s) of Exposure MOBILE CLINIC COMMERCIAL VEHICLES AMBULANCES WHEEL CHAIR VANS Deposit Premium: $ 108,801 Minimum Premium: $ 108,801 Rate(s) Estimated Prenium(s) 893.0000000 $ 893 1471.0000000 $ 44,130 3074.0000000 $ 52,258 2880.0000000 $ 11,520 U CA 411 C CW 04 109 Page1d2 or 2 Paragraph at Premium Audt of Section IV - Budness Auto Condtlons In the BUSINESS AUTO COVERAGE FORM, Paragraph B.6. Prenum Audt of Section V —Garage Condlons in the GARAGE COVERAGE FORM, Paragraph at Premium Audt of Section V — Motor Carder Condtlons in the MOTOR CARRIER COVERAGE FORM, and Paragraph B.6. Premium Audt of Section V — Truckers Condtlons in the TRUCKERS COVERAGE FORM are replaced by the following: 6. PremiumAudt a. The estimated premium for this Coverage Form Is based on the exposures you told us you would have when this policy began. Within 180 days after this Coverage Part expires we will conduct an audit, which may not be waived. 1Ab will compute the earned premium for the policy period by multiplying the composite rate against the total developed exposure. If the earned premium is greater than the sum of the deposit premiums, the first Named Insured will pay us the excess; if less, we will return the unearned portion to the first Named Insured. However, the earned premium will not be less than the estimated annual premium, or the Minimum Premium shown in the Schedule, whichever is greater. b. For policies other than Annual Reporting, the deposit premium shown in the Schedule is due and payable on the first day of the policy period. The first Named Insured will pay, within 20 days following the mailing or delivery of the statement of audited premium for each audit period, the earned premium due. c. If this policy is Issued for more than one year, the premium for this Coverage Form will be computed annually based on our rates or premiums in effect at the beginning of each year of the policy. d. The first Named Insured must maintain records of the information we need for premium computation and send us copies at such times as we may request. e. The units of exposure shown in the Schedule as used in this endorsement are defined as follows: (1) auto" means the actual number of covered "autos" at policy inception date added to the actual number of covered "autos" at policy expiration date or termination date and the total divided by 2 (2) "auto — power units only" means the actual number of covered "autos — power units only" at policy inception date added to the actual number of covered "autos — power units only" at policy expiration date or termination date and the total divided by 2. It includes "autos" operated under its own power only. (3) 'Cost of Hire" means the total cost of hiring the "autos". If autos" are hired without operators, include the actual wages of the operators of such 'autos". (4) "Gross receipts" means the total amount earned by the insured for shipping or transporting property. It includes: (a) The total amount received from the rental of equipment with or without drivers, to any person or organization not engaged in the business of transporting property for hire by auto", and (b) .15 of the total amount received from the rental of equipment, with or without drivers, to any person or organization engaged in the business of transporting property for hire by "auto". (1) "Gross receipts" do not include: (a) Amounts paid to air, sea or land carriers operating under their own permits. (b) Taxes collected as a separate item and paid directly to the government. (c) Cash on delivery collections for cost of merchandise including collection fees. (d) Warehouse storage charges. (e) Advertising revenue. (2) These definitions apply whether shipment originates with the insured or some other carrier. (5) "Miles" means the total mileage driven during the policy period by all revenue producing "autos". (6) 'Payroll" means total remuneration for all employees of the insured. (7) "Other" means the unit of exposure described in this endorsement. U CA411 CCW04 /09 Page 2 oft Schedule of Auto Physical Damage Deductibles The Schedule set forth below identifies the Deductible to apply to the Coverage(s) and Vehicle(s) described. Coverage COMPREHENSIVE COLLISION COMPREHENSIVE COLLISION SCHEDULE VehICie Desdiptbn COMPOSITE AUTO SCHEDULE COMPOSITE AUTO SCHEDULE AIRED CAR PHYSICAL DAMAGE HIRED CAR PHYSICAL DAMAGE Copyright Zurich American Insurance Company 2006 9) ZURICH $ Deductible 500 500 100 500 U.CA-548-A Cw (10/06) Page 1 of 1 POLICY NUMBER: RAP 9474903-01 ZURICH AMERICAN INSURANCE COMPANY 1400 AmerIcan Lana Schaumburg, Illinois 60196-1056 1-800-382-2150 BUSINESS AUTO DECLARATIONS ITEM ONE COMMERCIAL AUTO PRODUCER: THOMPSON INSURANCE ENTERPRISES NAMED INSURED: POUDRE VALLEY HEALTH CARE INC (SEE NAMED INSURED ENDORSEMENT) MAILING ADDRESS: 2315 E. HARMONY RD STE 200 FORT COLLINS, CO 8052.8 POLICY PERIOD: From 05-01-2012 to 05-01-2013 at 12:01 A.M. Standard Time at your mailing address shown above PREVIOUS POLICY NUMBER: BAP 9474903-00 FORM OF BUSINESS: CORPORATION LIMITED LIABILITY COMPANY p-1 INDIVIDUAL Ti PARTNERSHIP pi OTHER LX IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. Premium shown is payable at inception: $ 110,297.00 AUDIT PERIOD (IF APPLICABLE) ANNUALLY SEMI- ANNUALLY QUARTERLY MONTHLY ENDORSEMENTS ATTACHED TO THIS POLICY: IL 00 17 —Common Policy Conditions (IL 01 46in Washington) IL 00 21 —Broad Form Nuclear Exclusion (Not Applicable in New York) SEE SCHEDULE OF FORMS AND ENDORSEMENTS COUNTERSIGNED BY (Date) (Authorized Representative) NOTE OFFICERS' FACSIMILE SIGNATURES MAY BE INSERTED HERE, ON THE POLICY COVER CR ELSEWHERE AT THE COMPANY'S OPTION. U -CA -D -600B 0610 Page 1 ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those'butes" shown as covered'butes". ?Autos -are shown as covered 'hubs" for a particular coverage by the entry of one or pore of the symbols from the Cowed Autos Section of the Business Auto Cowrage Form next to the name of the coverage. COVERAGES COVERED AUTOS LIMIT PREMIUM LIABILITY 2,8,9 $1,000,000 $ 91,565 PERSONAL INJURY PROTECTION (or equivalent No-fault Coverage) SEPARATELY STATED IN EACH P.I.P. ENDORSEMENT MINUS DEDUCTIBLE. ADDED PERSONAL INJURY PROTECTION (or equivalent Added No-fault Coverage) SEPARATELY STATED IN EACH ADDED P.I.P. ENDORSEMENT. PROPERTY PROTECTION INSURANCE (Michigan only) SEPARATELY STATED IN THE P.P.I. ENDORSEMENT MINUS DEDUCTIBLE FOR EACH ACCIDENT. AUTO MEDICAL PAYMENTS MEDICAL EXPENSE AND INCOME LOSS BENEFITS (Virginia only) SEPARATELY STATED IN THE MEDICAL EXPENSE AND INCOME LOSS BENEFITS ENDORSEMENT. UNINSURED MOTORISTS 2 $ 1,000,000 TNCTJ UNDERINSURED MOTORISTS (When not included in Uninsured Motorists Coverage) 2 SEE ENDT TNCL PHYSICAL DAMAGE COMPREHENSIVE COVERAGE 10 ACTUAL CASH VALUE OR COST OF REPAIR, WHICHEVER IS LESS, MINUS SEE ENDT DEDUCTIBLE FOR EACH COVERED AUTO, BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. See ITEM FOUR For Hired or Borrowed Autos. e 5,082 PHYSICAL DAMAGE SPECIFIED CAUSES OF LOSS COVERAGE ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM. See ITEM FOUR For Hired Or Borrowed Autos. PHYSICAL DAMAGE COLLISION COVERAGE 10 ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, MINUS SEE ENDT DEDUCTIBLE, FOR EACH COVERED AUTO. See ITEM FOUR For Hired Or Borrowed Autos. $ 1.3,650 PHYSICAL DAMAGE TOWING AND LABOR FOR EACH DISABLEMENT OF A PRIVATE PASSENGER AUTO. TAX/SURCHARGE/FEE PREMIUM FOR ENDORSEMENTS `ESTIMATED TOTAL PREMIUM $ 110,297.00 'This policy may be subject to final audit. U -CA -D -600B 0610 Page 2 ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS LIABILITY COVERAGE —Cost Of Hlre Rating Basis for Autos Used In Your Motor Carder Operations (Other Than Moble Or Farm Equipment) LIABILITY COVERAGE ESTIMATED ANNUAL COST OF HIRE FOR ALL STATES PREMIUM _ Primary Coverage Excess Coverage IF ANY TNCL TOTAL PREMIUM [NCI For "autos" used in your motor carrier operations, cost of hire means: (a) The total dollar amount of costs you incurred for the hire of automobiles (includes "trailers" and semitrailers), and if not included therein, (b) The total remunerations of al operators and drivers' helpers, of hired automobiles whether hired with a driver by lessor or an "employee" of the lessee, or any other third party, and (c) The total dollar amount of any other costs (Le., repair, maintenance, fuel, eta) directly associated with operating the hired automobiles whether such costs are absorbed by the' insured", paid to the lessor or owner, or paid to others. LIABILITY COVERAGE — Cost Of Hire Rating Basis for Autos NOT Used in Your Motor Carder Operations (Other Than Moble Or Farm Equipment) LIABILITY COVERAGE STATE ESTIMATED ANNUAL COST OF HIRE FOR EACH STATE PREMIUM Primary Coverage Excess Coverage TOTAL PREMIUM For "autos" NOT used in your motor carrier operations, cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. U -CA -D -600B 0610 Page 3 ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd) Physical Damage Coverages —Cost Of Hire Rating Basis For All Autos (Other Than Mobile or Farm EqulpmeM) COVERAGE STATE LIMIT OF INSURANCE ESTIMATED ANNUAL COST OF HIRE FOR EACH STATE (Excluding Autos Hired WtthA Driver PREMIUM COMPREHENSIVE ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO, BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. SPECIFIED CAUSES OF LOSS ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM, COLLISION CO ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, MINUS $ 500 DEDUCTIBLE FOR EACH COVERED AUTO. $50,000 INCL TOTAL PREMIUM INCL For Physical Damage Coverages, cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members . Cost of hire does not include charges for any 'auto" that is leased, hired, rental or borrowed with a driver. - UCA-D-600B 0610 Page 4 ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd) Cost Of Hire Rating Basis For Mobile Or Farm Equipment — Other Than Physical Damage Coverages COVERAGE STATE ESTIMATED ANNUAL COST OF HIRE FOR EACH STATE PREMIUM Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Liability - Primary Coverage Liability - Excess Coverage Personal Injury Protection Medical Expense Benefits (Virginia Only) Income Loss Benefits (Virginia Only) Auto Medical Payments TOTAL PREMIUMS Cost of hire means the total amount you incur for the hire of "autos" you don't own (not Including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. U -CA -D -600B 0610 Page 5 ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd) Cost Of Hire Rating Basis For Mobile or Fann Equipment — Physical Damage Coverages COVERAGE STATE U MIT OF INSURANCE ESTIMATED ANNUAL COST OF HIRE FOR EACH STATE (Excluding Autos Hired With ADriver) PREMIUM _ Mobile Equipment Farm Equiment Mobile Equipment Farm Equipment COMPREHENSIVE ACTUAL CASH VALUE OR COST OF REPAIR, WHICH- EVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO, BUT NO DEDUCTIBLE AP- PLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. SPECIFIED CAUSES OF LOSS ACTUAL CASH VALUE OR COST OF REPAIR, WHICH- EVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO FOR LOSS CAUSED BY MIS- CHIEF OR VANDALISM. COLLISION ACTUAL CASH VALUE OR COST OF REPAIR, WHICH - EVER IS LESS, MINUS DEDUCTIBLE FOR EACH COVERED AUTO. TOTAL PREMIUM For Physical Damage Coverages, cost of hire means the total amount you incur for the h're of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for any auto that is leased, hired, rented or borrowed with a driver. U -CA -D -600B 0610 Page 6 ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Coned) Rental Period Rating Basis For Mobile Or Farm Equipment COVERAGE TOWN AND STATE WHERE THE JOB SITE IS LOCATED ESTIMATED NUMBER OF DAYS EQUIPMENT WILL BE RENTED PREMIUM Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Liability — Primary Coverage Liability — Excess Coverage Personal Injury Protection Medical Expense Benefits (Virginia Only) Income Loss Benefits (Virginia Only) Auto Medical Payments TOTAL PREMIUMS I ITEM FIVE SCHEDULE FOR NON -OWNERSHIP LIABILITY NAMED INSURED'S BUSINESS RATING BASIS NUMBER PREMIUM Other Than Garage Service Operations And Other Than Social Service Agencies Number Of Employees 1 9 6 INCL Number Of Partners (Active and Inactive) _ Garage Sante Operations Number Of Employees Whose Princi- pal Duty Involves The Operation Of Autos Number Of Partners (Active and Inactive) Social Service Agencies Number Of Employees Number Of Volunteers Who Regularly Use Autos To Transport Clients Number Of Partners (Active and Inactive) Total Premium INCI, U -CA -D -600B 0610 Page 7 ITEM SIX SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS Type Of Risk (Check one): U Public Autos I I Leasing Or Rental Concerns Rating Basis (Check one): I I Gross Receipts (Per;100) I I Mileage (Per Mie) Estimated Yearly (Check One): I I Gross Receipts (Per ;100) I I Mileage Premiums Liability Personal !flinty Protection Added Personal Injury Protection Property Protection Insurance (Michigan Only) Auto Medical Payments Medical Expense And Income Loss Benefits (Virginia Only) Comprehensive Specified Causes Of Loss Collision Towing And Labor Wnen used as a premium basis: FOR PUBLIC AUTOS Gross receipts means the total amount earned by the named Insured for transporting passengers, mall and merchan- dise. Gross receipts does not include: A. Amounts pad to air, sea or land carriers operating under their own permits. B. Advertising revenue. C. Taxes collected as a separate item and paid directly to the government. D. C.O.D. collections for cost of mail or merchandise including collection fees. Mileage means the total live and dead mileage of all revenue producing "autos" during the policy period. FOR RENTAL OR LEASING CONCERNS Gross receipts means the total amount caned by the named insured for the leasing or renting of "autos" to others without drivers. Mileage means the total live and dead mileage of all "autos" you leased or rented to others without drivers. U -CA -D-6008 0610 Page 0 COMMERCIAL AUTO CA 00 01 0310 BUSINESS AUTO COVERAGE FORM Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what is and Is not covered. Throughout this policy the words "you" and "your" re- fer to the Named Insured shown in the Declarations. The words 'We", "us" and "our" refer to the company providing this insurance. Other words and phrases that appear in quotation marks have special meaning. Refer to Section V — Definitions. SECTION I —COVERED AUTOS Item Two of the Declarations shows the "autos" that are covered "autos" for each of your coverages. The following numerical symbols describe the "autos" that may be covered "autos". The symbols entered next to a coverage on the Declarations designate the only "autos" that are covered "autos". A Description Of Covered Auto Designation Symbols Symbol Description Of Covered Auto Designation Symbols 1 Any "Auto" 2 Owned "Autos" Only Only those "autos" you own (and for Liability Coverage any "trailers" you don't own while attached to power units you own). This includes those "autos" you acquire ownership of after the policy begins. 3 Owned Private Passenger "Autos" Only Only the private passenger "autos" you own. This includes those private passenger "autos" you acquire ownership of after the policy begins. 4 Owned "Autos" Other Than Private Passenger "Autos" Only Only those "autos" you own that are not of the private passenger type (and for Liability Coverage any "trailers" you don't own while attached to power units you own). This includes those "autos" not of the private passenger type you acquire ownership of after the policy begins, _ 5 Owned "Autos" Subject To No-fault Only those "autos" you own that are required to have no-fault benefits in the state where they are licensed or principally garaged. This includes those "autos" you acquire ownership of after the policy begins provided they are required to have no- fault benefits in the stale where they are licensed or principally garaged. 6 Owned "Autos" Subject To A Compulsory Uninsured Motorists Law Only those "autos" you own that because of the law in the state where they are licensed or principally garaged are required to have and cannot reject Uninsured Motorists Coverage. This Includes those "autos" you acquire ownership of after the policy begins provided they are subject to the same state uninsured motorists requirement. 7 Specifically Described "Autos" Only those "autos" described in Item Three of the Declarations for which a premium charge Is shown (and for Liability Coverage any "trailers" you don't own while attached to any power unit described in Item Three). 8 Hired "Autos" Only Only those "autos" you lease, hire, rent or borrow. This does not include any "auto" you lease, hire, rent or borrow from any of your "employees", partners (if you are a partnership), members (if you are a limited liability company) or members of their households. 9 Non -owned "Autos" Only Only those "autos" you do not own, lease, hire, rent or borrow that are used in connection with your business. This includes "autos" owned by your "employees", partners (if you are a partnership), members (if you are a limited liability company) or members of their households but only while used in your business or your personal affairs. CA00010310 0 Insurance Services Office, Inc., 2009 Page 1 of 12 O 19 Mobile Equip- ment Subject To Compulsory Or Financial Responsibility Or Other Motor Vehicle Insur- ance Law Only Only those "autos" that are land vehicles and that would qualify under the definition of"mobile equipment" under this policy if they were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where they are licensed or principally garaged. B. Owned Autos You Acquire After The Policy Begins 1. If Symbols 1, 2, 3, 4, 5, 6 or 19 are entered next to a coverage in Item Two of the Declarations, then you have coverage for "autos" that you acquire of the type described for the remainder of the policy period. 2. But, if Symbol 7 Is entered next to a coverage in Item Two of the Declarations, an "auto" you acquire will be a covered "auto" for that cover- age only if: a. We already cover all "autos" that you own for that coverage or it replaces an "auto" you previously owned that had that cover- age; and b. You tell us within 30 days after you acquire it that you want us to cover it for that cover- age. C. Certain Trailers, Mobile Equipment And Temporary Substitute Autos If Liability Coverage is provided by this coverage form, the following types of vehicles are also cov- ered "autos" for Liability Coverage: 1. 'Trailers" with a load capacity of 2,000 pounds or less designed primarily for travel on public roads. 2. "Mobile equipment" while being carried or towed by a covered "auto". 3. Any "auto" you do not own while used with the permission of its owner as a temporary substi- tute for a covered "auto" you own that is out of service because of Its: a. Breakdown; b. Repair; c. Servicing; d. 'Loss"; or a. Destruction. Page 2 of 12 SECTION II —LIABILITY COVERAGE A. Coverage We will pay all sums an "Insured" legally must pail as damages because of 'bodily injury' or 'property damage" to which this Insurance applies, caused by an "accident" and resulting from the ownership, maintenance or use of a covered "auto". We will also pay all sums an 'Insured" legally must pay as a "covered pollution cost or expense" to which this insurance applies, caused by an "acci- dent" and resulting from the ownership, mainte- nance or use of covered "autos". However, we will only pay for the "covered pollution cost or ex- pense" if there is either 'bodily injury" or "property damage" to which this insurance applies that is caused by the same "accident". We have the right and duty to defend any insured" against a "suit" asking for such damages or a "covered pollution cost or expense". However, we have 'no duty to defend any 'insured" against a "suit" seeking damages for "bodily injury" or "prop- erly damage" or a "covered pollution cost or ex- pense" to which this insurance does not apply. We may investigate and settle any claim or "suit" as we consider appropriate. Our duty to defend or settle ends when the Liability Coverage Limit of Insurance has been exhausted by payment of judgments or settlements. 1. Who Is An Insured The following are 'insure Is": a. You for any covered "auto". b. Anyone else while using with your permis- sion a covered "auto" you own, hire or bor- row except: (1) The owner or anyone else from whom you hire or borrow a covered "auto". This exception does not apply If the covered "auto" is a 'trailer" connected to a covered "auto" you own. © Insurance Services Office, Inc., 2009 CA00010310 In (2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her household. (3) Someone using a covered "auto" while he or she is working In a business of selling, servicing, repairing, parking or storing "autos" unless that business is yours. (4) Anyone other than your "employees", partners (if you are a partnership), members (if you are a limited liability company) or a lessee or borrower or any of their "employees", while moving property to or from a covered 'auto". (5) A partner (if you are a partnership) or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household. c. Anyone liable for the conduct of an 'in- sured" described above but only to the ex- tent of that liability. 2. Coverage Extensions a. Supplementary Payments We will pay for the insured": (1) All expenses we incur. (2) Up to $2,000 for cost of bail bonds (in- cluding bonds for related traffic law vio- lations) required because of an "acci- dent" we cover. We do not have to fur- nish these bonds. The cost of bonds to release attach- ments in any "suit" against the 'Insured" we defend, but only for bond amounts within our Limit of Insurance. (4) All reasonable expenses incurred by the 'insured" at our request, including actual loss of earnings up to $250 a day be- cause of lime off from work. All court costs taxed against the 'In- sured" in any "suit" against the insured" we defend. However, these payments do not include attorneys' fees or attorneys' expenses taxed against the 'insured". All interest on the full amount of any judgment that accrues after entry of the judgment in any "suit" against the In- sured" we defend, but our duty to pay interest ends when we have paid, of- fered to pay or deposited in court the part of the judgment that is within our Limit of Insurance. (3) (5) (6) CA00010310 These payments will not reduce the Limit of Insurance. b. Out-of-state Coverage Extensions While a covered "auto" Is away from the state where it is licensed we will: (1) Increase the Limit of Insurance for Li- ability Coverage to meet the limits speci- fied by a compulsory or financial re- sponsibility law of the jurisdiction where the covered "auto" is being used. This extension does not apply to the limit or limits specified by my law governing motor carriers of passengers or prop- erty. (2) Provide the minimum amounts and types of other coverages, such as no-fault, required of out -of -slate vehicles by the jurisdiction where the covered "auto" is being used. We will not pay anyone more than once for the same elements of loss because of these extensions. B. Exclusions This insurance does not apply to any of the follow- ing: 1. Expected Or Intended Injury Bodily injury" or 'property damage" expected or intended from the standpoint of the in- sured". 2. Contractual Liability assumed under any contract or agreement. But this exclusion does not apply to liability for damages: a. Assumed in a contract or agreement that is an insured contract" provided the "bodily injury" or 'property damage" occurs subse- quent to the execution of the contract or agreement; or h. That the Insured" would have in the ab- sence of the contract or agreement. 3. Workers' Compensation Any obligation for which the "Insured" or the ' insured's" insurer may be held liable under any workers' compensation, disability benefits or unemployment compensation law or any similar law. ©Insurance Services Office, Inc., 2000 Page 3of12 ❑ 4. Employee Indettn1lcatlon And Employer's Liability 'Bodily Injury" to: a. An "employee" of the 'Insured" arising out of and in the course of: (1) Employment by the 'Insured"; or (2) Performing the duties related to the conduct of the'Insured's" business; or b. The spouse, child, parent, brother or sister of that "employee" as a consequence of Pa- ragraph a. above. This exclusion applies: (1) Whether the Insured" may be liable as an employer or in any other capacity, and (2) To any obligation to share damages with or repay someone else who must pay damages because of the injury. But this exclusion does not apply to "bodily In- jury" to domestic "employees" not entitled to workers' compensation benefits or to liability assumed by the 'Insured" under an 'Insured contract". For the purposes of the coverage form, a domestic "employee" Is a person en- gaged In household or domestic work per- formed principally in connection with a resi- dence premises. 5. Fellow Employee 'Bodily injury" to: a. My fellow "employee" of the Insured" aris- ing out of and in the course of the fellow "employee's" employment or while perform- ing duties related to the conduct of your business; or b. The spouse, child, parent, brother or sister of that fellow "employee" as a consequence of Paragraph a above. 6. Care, Custody Or Control Property damage" to or "covered pollution cost or expense" involving property owned or trans- ported by the 'Insured" or in the 'Insured's" care, custody or control. But this exclusion does not apply to liability assumed under a si- detrack agreement. 7. Handling Of Property 'Bodily injury' or "property damage" resulting from the handling of property. a. Before it is moved from the place where it is accepted by the "insured" for movement into or onto the covered "auto"; or Page 4 of 12 h. After it is moved from the covered "auto" to the place where it is finally delivered by the Insured". IL Movement Of Property By Mechanical Device 'Bodily injury" or "property damage" resulting from the movement of property by a mechani- cal device (other than a hand truck) unless the device is attached to the covered "auto". 9. Operations 'Bodily injury" or "property damage" arising out of the operation of: a. Any equipment listed in Paragraphs 6.b. and 6.c. of the definition of "mobile equip- ment"; or b. Machinery or equipment that Is on, attached to or part of a land vehicle that would qual- ify under the definition of "mobile equip- ment" if it were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it Is licensed or principally garaged. 10. Completed Operations "Bodily injury" or 'property damage" arising out of your work after that work has been com- pleted or abandoned. In this exclusion, your work means: a. Work or operations performed by you or on your behalf; and b. Materials, parts or equipment furnished in connection with such work or operations. Your work includes warranties or representa- tions made at any time with respect to the fit- ness, quality, durability or performance of any of the items included in Paragraph a. or b. above. Your work will be deemed completed at the earliest of the following times: (1) When all of the work called for in your contract has been completed. (2) When all of the work to be done at the site has been completed if your contract calls for work at more than one site. (3) When that part of the work done at a job site has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. © Insurance Services Office, Inc., 2009 CA 00 0103 10 Work that may need service, maintenance, cor- rection, repair or replacanent, but which is otherwise complete, will be treated as com- pleted. 11. Pollution "Bodily injury" or "property damage" arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or es- cape of 'pollutants": a. That are, or that are contained In any prop- erty that is: (1) Being transported or towed by, handled or handled for movement into, onto or from the covered "auto"; (2) Otherwise in the course of transit by or on behalf of the "Insured" or (3) Being stored, disposal of, treated or processed in or upon the covered "au- to"; b. Before the "pollutants" or any property in which the 'pollutants" are contained are moved from the place where they are ac- cepted by the 'Insured" for movement into or onto the covered "auto"; or c. After the "pollutants" or any property in which the "pollutants" are contained are moved from the covered "auto" to the place where they are finally delivered, disposed of or abandoned by the'Insured". Paragraph a. above does not apply to fuels, lu- bricants, fluids, exhaust gases or other similar "pollutants" that are needed for or result from the normal electrical, hydraulic or mechanical functioning of the covered "auto" or its parts, if: (1) The "pollutants" escape, seep, migrate or are discharged, dispersed or released directly from an "auto" part designed by its manufacturer to hold, store, receive or dispose of such "pollutants"; and (2) The 'bodily injury", "property damage." or "covered pollution cost or expense" does not arise out of the operation of any equipment listed in Paragraphs 6.b. and 6.c. of the definition of "mobile equipment". CA 00 01 03 10 Paragraphs b. and c. above of this exclusion do not apply to "accidents" that occur away from premises owned by or rented to an'In- sured" with respect to "pollutants" not In or upon a covered "auto" if: (a) The "pollutants" or any property In which the "pollutants" are contained are upset, overturned or damaged as a result of the maintenance or use of a covered "auto"; and (b) The discharge, dispersal, seepage, mi- gration, release or escape of the "pollut- ants" Is caused directly by such upset, overturn or damage. 12. War "Bodily injury" or "property damage" arising di- rectly or indirectly out of: a. War, including undeclared or civil war; b. Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any govern- ment, sovereign or other authority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power or action taken by governmental au- thority in hindering or defending against any of these. 13. RacIng Covered "autos" while used in any professional or organized racing or demolition contest or stunting activity, or while practicing for such contest or activity. This insurance also does not apply while that covered "auto" is being prepared for such a contest or activity. C. Limit Of Insurance Regardless of the number of covered "autos",'In- sureds", premiums paid, claims made or vehicles involved in the "accident", the most we will pay for the total of all damages and "covered pollution cost or expense" combined resulting from any one "accident" is the Limit of Insurance for Liability Coverage shown in the Declarations. © Insurance Services Office, Inc., 2009 Page5of12 ❑ A l "bodily injury", "property damage" and "covered pollution cost or expense" resulting from continu- ous or repeated exposure to substantially the sane conditions will be considered as resulting from one "accident". No one will be entitled to receive duplicate pay- ments for the same elements of loss" under this coverage form and any Medical Payments Cover- age endorsement, Uninsured Motorists Coverage endorsement or Underinsured Motorists Coverage endorsement attached to this Coverage Part. SECTION III —PHYSICAL DAMAGE COVERAGE A. Coverage 1. We will pay for 'loss" to a covered "auto" or its equipment under: a. Comprehensive Coverage From any cause except: (1) The covered "auto's" collision with an- other object; or (2) The covered "auto's" overturn. b. Specified Causes Of Loss Coverage Caused by: (1) Fire, lightning or explosion; (2) Theft; (3) Windstorm, hail or earthquake; (4) Flood; (5) Mischief or vandalism; or (6) The sinking, burning, collision or derail- ment of any conveyance transporting the covered "auto". c. Collision Coverage Caused by: (1) The covered "auto's" collision with an- other object; or (2) The covered "auto's" overturn. 2. Towing We will pay up to the limit shown in the Decla- rations for towing and labor costs incurred each time a covered "auto" of the private pas- senger type is disabled. However, the labor must be performed at the place of disablement. 3. Glass Breakage—HlttIng A Bird Or Animal — Falling Objects Or Missiles If you carry Comprehensive Coverage for the damaged covered "auto", we will pay for the following under Comprehensive Coverage: a. Glass breakage; b. 'Loss" caused by hitting a bird or animal; and c. 'Loss" caused by falling objects or missiles. However, you have the option of having glass breakage caused by a covered "auto's" collision or overturn considered a 'loss" under Collision Coverage. 4. Coverage Extensions a. Transportation Expenses We will pay up to $20 per day to a maximum of $600 for temporary transportation expense incurred by you because of the to- tal theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes Of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expi- ration, when the covered "auto" is returned to use or we pay for its 'loss". b. Loss Of Use Expenses For Hired Auto Physical Damage, we will pay expenses for which an Insured" be- comes legally responsible to pay for loss of use of a vehicle rented or hired without a driver under a written rental contract or agreement. We will pay for loss of use ex- penses if caused by: (1) Other than collision only if the Declara- tions indicate that Comprehensive Cov- erage is provided for any covered "auto"; (2) Specified Causes Of Loss only if the Declarations indicate that Specified Causes Of Loss Coverage is provided for any covered "auto"; or (3) Collision only if the Declarations indicate that Collision Coverage is provided for any covered "auto". However, the most we will pay for any ex- penses for loss of use is $20 per day, to a maximum of $600. B. Exclusions 1. We will not pay for 'loss" caused by or resulting from any of the following. Such 'loss" is ex- cluded regardless of any other cause or event that contributes concurrently or in any se- quence to the 'loss". a. Nuclear Hazard (1) The explosion of any weapon employing atomic fission or fusion; or (2) Nuclear reaction or radiation, or radioac- tive contamination, however caused. Page 6 of 12 O Insurance Services Office, Inc., 2009 CA 00 01 0310 O b. War Or Military Action (1) War, including undeclared or civil war; (2) Warlike action by a military force, Includ- ing action in hindering or defending against an actual or expected attack, by any government, sovereign or other au- thority using military personnel or other agents; or (3) Insurrection, rebellion, revolution, usurped power or action taken by gov- ernmental authority in hindering or de- fending against any of these. 2. We will not pay for loss" to any covered "auto" while used in any professional or organized racing or demolition contest or stunting activ- ity, or while practicing for such contest or activ- ity. We will also not pay for loss" to any covered "auto" while that covered "auto" is being prepared for such a contest or activity. 3. We will not pay for 'loss" due and confined to: a. Wear and tear, freezing, mechanical or electrical breakdown. b. Blowouts, punctures or other road damage to tires. This exclusion does not apply to such 'loss" resulting from the total theft of a covered "au- to". 4. We will not pay for 'loss" to any of the follow- ing: a. Tapes, records, discs or other similar audio, visual or data electronic devices designed for use with audio, visual or data electronic equipment. b. My device designed or used to detect speed -measuring equipment such as radar or laser detectors and any jamming appara- tus intended to elude or disrupt speed - measurement equipment. c. Any electronic equipment, without regard to whether this equipment Is permanently in- stalled, that reproduces, receives or trans- mits audio, visual or data signals. d. My accessories used with the electronic equipment described in Paragraph c. above. 5. Exclusions 4.c. and 4.d. do not apply to equipment designed to be operated solely by use of the power from the "auto's" electrical system that, at the time of 'loss", is: a. Permanently installed in or upon the cov- ered "auto"; CA 00 01 0310 b. Removable from a housing unit which is permanently installed in or upon the cov- ered "auto"; c. An integral part of the sane unit housing any electronic equipment described in Pa- ragraphs a. and b. above; or d. Necessary for the normal operation of the covered "auto" or the monitoring of the covered "auto's" operating system. 6. We will not pay for 'loss" to a covered "auto" due to "diminution in value". C. Limit Of Insurance 1. The most we will pay for 'loss" in any one "ac- cident" is the lesser of: a. The actual cash value of the damaged or stolen property as of the time of the 'loss"; or b. The cost of repairing or replacing the dam aged or stolen property with other property of like kind and quality. 2. $1,000 is the most we will pay for 'loss" in any one "accident" to all electronic equipment that reproduces, receives or transmits audio, visual or data signals which, at the time of'loss", is: a. Permanently installed in or upon the cov- ered "auto" in a housing, opening or other location that is not normally used by the "auto" manufacturer for the installation of such equipment; b. Removable from a permanently installed housing unit as described in Paragraph 2.a. above or is an integral part of that equip- ment; or c. An Integral part of such equipment. 3. An adjustment for depreciation and physical condition will be made in determining actual cash value in the event of a total loss". 4. If a repair or replacement results in better than like kind or quality, we will not pay for the amount of the betterment. D. Deductible For each covered "auto", our obligation to pay for, repair, return or replace damaged or stolen prop- erty will be reduced by the applicable deductible shown in the Declarations. My Comprehensive Coverage deductible shown in the Declarations does not apply to loss" caused by fire or lightning. © Insurance Services Office, Inc., 2009 Page 7 of 12 ❑ SECTION IV -BUSINESS AUTO CONDITIONS The following conditions apply in addition to the Common Policy Conditions: A Loss Conditions 1. Appraisal For Physical Damage Loss If you and we disagree on the amount of 'loss", either may demand an appraisal of the loss". In this event, each party will select a competent appraiser. The two appraisers will sdect a competent and impartial umpire. The appraisers will state separately the actual cash value and amount of 'loss". If they fail to agree, they will submit their differences to the umpire. A decision agreed to by any two will be binding. Each party will: a. Pay its chosen appraiser; and b. Bear the other expenses of the appraisal and umpire equally. If we submit to an appraisal, we will still retain our right to deny the claim. 2. Duties In The Event Of Accident, Claim, Suit Or Loss We have no duty to provide coverage under this policy unless there has been full compli- ance with the following duties: a. In the event of "accident", clam, "suit" or 'loss", you must give us or our authorized representative prompt notice of the "acci- dent" or 'loss". Include: (1) How, when and where the "accident" or 'loss" occurred; (2) The'Insured's" name and address; and (3) To the extent possible, the names and addresses of any injured persons and witnesses. b. Additionally, you and any other involved 'Insured" must: (1) Assume no obligation, make no payment or Incur no expense without our consent, except at the 'Insured's" own cost. (2) Immediately send us copies of any re- quest, demand, order, notice, summons or legal paper received concerning the claim or "suit". (3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit". (4) Authorize us to obtain medical records or other pertinent Information. Page 8 o112 (5) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably require. c. If there is 'loss" to a covered "auto" or its equipment you must also do the following: (1) Promptly notify the police if the covered "auto" or any of its equipment is stolen. (2) Take all reasonable steps to protect the covered "auto" from further damage. Al- so keep a record of your expenses for consideration in the settlement of the claim. (3) Permit us to Inspect the covered "auto" and records proving the 'loss" before its repair or disposition. (4) Agree to examinations under oath at our request and give us a signed statement of your answers. 3. Legal Action Against Us No one may bring a legal action against us un- der this coverage form until: a. There has been full compliance with all the terms of this coverage form; and b. Under Liability Coverage, we agree in writ- ing that the 'Insured" has an obligation to pay or until the amount of that obligation has finally been determined by judgment af- ter trial. No one has the right under this pol- icy to bring us into an action to determine the'Insured's" liability. 4. Loss Payment —Physical Damage Coverages At our option we may: a. Pay for, repair or replace damaged or stolen property; b. Return the stolen property, at our expense. We will pay for any damage that results to the "auto" from the theft; or c. Take all or any part of the damaged or sto- len property at an agreed or appraised val- ue. If we pay for the 'loss", our payment will in- clude the applicable sales tax for the damaged or stolen properly. 5. Transfer Of Rights Of Recovery Against Others To Us If any person or organization to or for whom we make payment under this coverage form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or 'loss" to impair them. © Insurance Services Office, Inc., 2009 CA 00 01 03 10 O B. General Conditions 1. Bankruptcy Bankruptcy or insolvency of the 'insured" or the "Insured's" estate will not relieve us of any obligations under this coverage form. 2. Concealment, Misrepresentation Or Fraud This coverage form Is void in any case of fraud by you at any time as it relates to this coverage form. It is also void if you or any other in- sured", at any time, intentionally conceal or misrepresent a material fact concerning: a. This coverage form; b. The covered "auto"; c. Your interest in the covered "auto"; or d. A claim under this coverage form. 3. Liberalization If we revise this coverage form to provide more coverage without additional premium charge, your policy will automatically provide the addi- tional coverage as of the clay the revision is ef- fective in your state. 4. No Benefit To Bailee — Physical Damage Coverages We will not recognize any assignment or grant any coverage for the benefit of any person or organization holding, storing or transporting property for a fee regardless of any other pro- vision of this coverage form. 5. Other Insurance a. For any covered "auto" you own, this cov- erage form provides primary insurance. For any covered "auto" you don't own, the in- surance provided by this coverage form is excess over any other collectible insurance. However, while a covered "auto" which is a "trailer" Is connected to another vehicle, the Liability Coverage this coverage form pro- vides for the "trailer" is' (1) Excess while It Is connected to a motor vehicle you do not own. (2) Primary while it is connected to a cov- ered "auto" you own. b. For Hired Auto Physical Damage Coverage, any covered "auto" you lease, hire, rent or borrow is deemed to be a covered "auto" you own. However, any "auto" that Is leased, hired, rental or borrowed with a driver is not a covered "auto". c. Regardless of the provisions of Paragraph a. above, this coverage form's Liability Coverage is primary for any liability as- sumed under an 'insured contract". CA00010310 d. When this coverage form and any other coverage form or policy covers on the sane basis, either excess or primary, we will pay only our share. Our share is the proportion that the Limit of Insurance of our coverage form bears to the total of the limits of all the coverage forms and policies covering on the same basis. 6. Premium Audit a. The estimated premium for this coverage form is based on the exposures you told us you would have when this policy began. We will compute the final premium due when we determine your actual exposures. The estimated total premium will be credited against the final premium due and the first Named Insured will be billed for the bal- ance, If any. The due date for the final pre- mium or retrospective premium Is the date shown as the due date on the bill. If the es- timated total premium exceeds the final premium due, the first Named Insured will get a refund. b. If this policy is issued for more than one year, the premium for this coverage form will be computed annually based on our rates or premiums in effect at the beginning of each year of the policy. 7. Policy Period, Coverage Territory Under this coverage form, we cover "accidents" and losses" occurring: a. During the policy period shown in the Dec- larations; and b. Wlhin the coverage territory. The coverage territory is: (1) The United States of America; (2) The territories and possessions of the Unit- ed States of America; Puerto Rico; Canada; and (3) (4) (5) Anywhere in the world if: (a) A covered "auto" of the private passen- ger type is leased, hired, rented or bor- rowed without a driver for a period of 30 days or less; and (b) The insureds" responsibility to pay damages is determined in a "suit" on the merits, in the United States of America, the territories and possessions of the United States of America, Puerto Rco or Canada or in a settlement we agree to. © Insurance Services Office, Inc., 2009 Page 0of12 ❑ We also cover 'loss" to, or "accidents" involv- ing, a covered "auto" while being transported between any of these places. 8. Two Or More Coverage Forms Or Policies Issued By Us If this coverage form and any other coverage form or policy issued to you by us or any com- pany affiliated with us applies to the sane "ac- cident", the aggregate maximum Limit of Insur- ance under all the coverage forms or policies shall not exceed the highest applicable Limit of Insurance under any one coverage form or pol- icy. This condition does not apply to any cov- erage form or policy issued by us or an affili- ated company specifically to apply as excess insurance over this coverage form. SECTION v- DEFINITIONS A. "Accident" includes continuous or repeated expo- sure to the same conditions resulting in 'bodily in- jury" or "property damage". B. "Auto" means: 1. A land motor vehicle, "trailer" or semitrailer de- signed for travel on public roads; or 2. Any other land vehicle that is subject to a com- pulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged. However, "auto" does not include 'mobile equip- ment'. C. 'Bodily injury" means bodily injury, sickness or disease sustained by a person including death re- sulting from any of these. D. "Covered pollution cost or expense" means any cost or expense arising out of: 1. Any request, demand, order or statutory or regulatory requirement that any 'Insured" or others test for, monitor, clean up, remove, con- tain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollut- ants"; or 2. Any claim or "suit" by or on behalf of a gov- ernmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of, "pollutants". Page 10 of 12 "Covered pollution cost or expense" does not In- clude any cost or expense arising out of the ac- tual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of "pollut- ants": a. That are, or that are contained in any prop- erty that is: (1) Being transported or towed by, handled or handled for movement into, onto or from the covered "auto"; (2) Otherwise in the course of transit by or on behalf of the insured"; or (3) Being stored, disposed of, treated or processed in or upon the covered "au- to"; b. Before the "pollutants" or any property In which the "pollutants" are contained are moved from the place where they are ac- cepted by the "Insured" for movement into or onto the covered "auto"; or c. After the "pollutants" or any property in which the "pollutants" are contained are moved from the covered "auto" to the place where they are finally delivered, disposed of or abandoned by the 'Insured". Paragraph a. above does not apply to fuels, lu- bricants, fluids, exhaust gases or other similar "pollutants" that are needed for or result from the normal electrical, hydraulic or mechanical functioning of the covered "auto" or Its parts, if: (1) The "pollutants" escape, seep, migrate or are discharged, dispersed or released directly from an "auto" part designed by its manufacturer to hold, store, receive or dispose of such "pollutants"; and (2) The 'bodily injury", "property damage" or "covered pollution cost or expense" does not arise out of the operation of any equipment listed In Paragraph 6.b. or 6.c. of the definition of "mobile equipment"- ® Insurance Services Office, Inc., 2009 CA00010310 ❑ Paragraphs b. and a above do not apply to "accidents" that occur away from premises owned by or rented to an insured" with respect to "pollutants" not in or upon a covered "auto" if: (a) The "pollutants" or any property in which the "pollutants" are contained are upset, overturned or damaged as a result of the maintenance or use of a covered "auto"; and (b) The discharge, dispersal, seepage, mi- gration, release or escape of the "pollut- ants" is caused directly by such upset, overturn or damage. E. "Diminution in value" means the actual or perceived loss in market value or resale value which results from a direct and accidental loss". F. "Employee" includes a 'leased worker". "Employee" does not include a "temporary worker". G. "Insured" means any person or organization quali- fying as an Insured In the Who Is An Insured pro- vision of the applicable coverage. Except with re- spect to the Limit of Insurance, the coverage af- forded applies separately to each insured who is seeking coverage or against whom a claim or "suit" is brought. H. "Insured contract" means: 1. A lease of premises; 2. A sidetrack agreement; 3. Any easement or license agreement, except in connection with construction or demolition op- erations on or within 50 feet of a railroad; 4. An obligation, as required by ordinance, to in- demnify a municipality, except in connection with work for a municipality; 5. That part of any other contract or agreement pertaining to your business (including an in- demnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another to pay for 'bodily injury" or "properly damage" to a third party or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement; 6. That part of any contract or agreement entered into, as part of your business, pertaining to the rental or lease, by you or any of your "employ- ees", of any "auto". However, such contract or agreement shall not be considered an "insured contract" to the extent that it obligates you or any of your "employees" to pay for "property damage" to any "auto" rented or leased by you or any of your "employees". CA 00 01 0310 An 'Insured contract" does not Include that part of any contract or agreement: a. That indemnifies a railroad for 'bodily injury" or "property damage" arising out of con- struction or demolition operations, within 50 feet of any railroad property and affecting any railroad bridge or trestle, tracks, road- beds, tunnel, underpass or crossing; b. That pertains to the loan, lease or rental of an "auto" to you or any of your "employees", if the "auto" is loaned, leased or rented with a driver; or c. That holds a person or organization en- gaged in the business of transporting prop- erty by "auto" for hire harmless for your use of a covered "auto" over a route or territory that person or organization is authorized to serve by public authority. I. "Leased worker" means a person leased to you by a labor leasing firm under an agreement between you and the labor leasing firm to perform duties re- lated to the conduct of your business. teased worker" does not include a "temporary worker". J. toss" means direct and accidental loss or dam- age. K "Mobile equipment' means any of the following types of land vehicles, Including any attached ma- chinery or equipment: 1. Bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; 2. Vehicles maintained for use solely on or next to premises you own or rent; 3. Vehicles that travel on crawler treads; 4. Vehicles, whether self-propelled or not, main- tained primarily to provide mobility to perma- nently mounted: a. Power cranes, shovels, loaders, diggers or drills; or b. Road construction or resurfacing equipment such as graders, scrapers or rollers; 5. Vehicles not described In Paragraph 1., 2., 3. or 4. above that are not self-propelled and are maintained primarily to provide mobility to per- manently attached equipment of the following types: a. Air compressors, pumps and generators, including spraying, welding, building clean- ing, geophysical exploration, lighting and well -servicing equipment; or b. Cherry pickers and similar devices used to raise or lower workers; or O Insurance Services Office, Inc., 2009 Page 11 of 12 ❑ 6. Vehicles not described in Paragraph 1., 2., 3. or 4. above maintained primarily for purposes other than the transportation of persons or car- go. However, self-propelled vehicles with the following types of permanently attached equipment are not "mobile equipment" but will be considered "autos": a. Equipment designed primarily for: (1) Snow removal; (2) Road maintenance, but not construction or resurfacing; or (3) Street cleaning b. Cherry pickers and similar devices mounted on automobile or truck chassis and used to raise or lower workers; and c. Air compressors, pumps and generators, including spraying, welding, building clean- ing, geophysical exploration, lighting or well -servicing equipment. However, "mobile equipment" does not include laid vehicles that are subject to a compulsory or financial responsibility law or other motor vehicle insurance Ian where it is licensed or principally ga- raged. Land vehicles subject to a compulsory or financial responsibility law or other motor vehicle insurance law are considered "autos". L. "Pollutants" means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed. Page 12 of 12 M. 'Property damage" means damage to or loss of use of tangible properly. N. "Suit" means a civil proceeding in which: 1. Damages because of "bodily injury" or "prop- erty damage"; or 2. A "covered pollution cost or expense"; to which this insurance applies, are alleged. "Suit" includes: a. An arbitration proceeding in which such damages or "covered pollution costs or ex- penses" are claimed and to which the'in- sured" must submit or does submit with our consent; or b. Any other alternative dispute resolution proceeding in which such damages or "covered pollution costs or expenses" are claimed and to which the insured submits with our consent. O. 'Temporary worker" means a person who is fur- nished to you to substitute for a permanent "em- ployee" on leave or to meet seasonal or short-term workload conditions. P. 'Trailer" includes semitrailer. © Insurance Services Office, Inc., 2009 CA00010310 O COMMERCIAL AUTO CA01130111 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CHANGES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. For a covered 'auto" licensed or principally garaged In, or "garage operations" conducted In, Colorado, the policy is changed as follows: A The following condition is added: If the 'Insured's" whereabouts for service of process cannot be determined through reasonable effort, the 'insured" agrees to designate and irrevocably appoint us as the agent of the 'insured" for service of process, pleadings, or other filings in a civil action brought against the 'insured" or to which the 'insured" has been joined as a defendant or respondent in any Colorado court if the cause of action concerns an incident for which the 'insured" can possibly claim coverage. Subsequent termination of the Insurance policy does not affect the appointment for an incident that occurred when the policy was in effect. The 'Insured" agrees that any such civil action may be commenced against the 'Insured' by the service of process upon us as if personal service had been made directly on the 'Insured". We agree to forward all communications related to service of process to the last -known e-mail and mailing address of the policyholder In order to coordinate any payment of claims or defense of claims that are required. CA01130111 B. Changes in Conditions The last paragraph in the Other Insurance Condition in the Business Auto and Garage Coverage Forms and the Other Insurance — Primary And Excess Insurance provisions in the Truckers and Motor Carrier Coverage Forms is replaced by the following: When this coverage form and any other coverage form or policy covers on the same basis, either excess or primary, the loss will be paid in accordance with the following method: 1. All applicable policies will pay on an equal basis until the policy with the lowest limit of insurance is exhausted. 2. If any loss remains and there: a. Are two or more remaining policies whose applicable limits of insurance have not been exhausted, then such policies will continue to pay in accordance with Paragraph 1.; or b. Is one remaining policy, then such policy will continue to pay until its limit of insurance has been exhausted. C Insurance Services Office, Inc., 2010 Page 1 of 1 ❑ COMMERCIAL AUTO CA 20 99 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO EMERGENCY SERVICES - VOLUNTEER FIREFIGHTERS' AND WORKERS' INJURIES EXCLUDED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. Liability Coverage is changed by adding the following exclusions: This insurance does not apply to: 1. 'Bodily injury" to any volunteer firefighter or other volunteer worker of the Insured" if sustained while such person is engaged in volunteer firefighting, rescue squad or ambulance corps operations. CA20990310 2. 'Bodily injury" to any fellow volunteer firefighter or other volunteer worker of the'insured" if sustained In the course of volunteer firefighting, rescue squad or ambulance corps operations. However, Paragraphs 1. and 2. above do not apply to 'bodily injury" to any volunteer for a fire department if sustained In a motor vehicle while responding to an emergency. © Insurance Services Office, Inc., 2009 Page 1 of 1 ❑ POLICY NUMBER BAP 9474903-01 COMMERCIAL AUTO CA21500111 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO UNINSURED MOTORISTS COVERAGE - BODILY INJURY For a covered "auto" licensed or principally garaged in, or "garage operations" conducted in, Colorado, this endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. SCHEDULE Llmk Of Insurance: $ 1, 0 0 0, 0 0 0 Each "Accident' Information required to complete this Schedule, if not shown above, will be shown in the Declarations. J A. Coverage 1. We will pay all sums the 'insured" is legally entitled to recover as compensatory damages from the owner or driver of an "uninsured motor vehicle". The damages must result from 'bodily injury" sustained by the 'insured" caused by an "accident". The owner's or driver's liability for these damages must result from the ownership, maintenance or use of the "uninsured motor vehicle". 2. With respect to damages resulting from an "accident" with a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle", we will pay under this coverage only if a. or b. below applies: a. The limits of any applicable liability bonds or policies have been exhausted by payment of judgments or settlements; or b. A tentative settlement has been made between an 'insured" and the insurer of a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle", and we: (1) Have been given prompt written notice of such tentative settlement; and (2) Advance payment to the "Insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. B. Who Is An Insured If the Named Insured is designated in the Declarations as: 1. An individual, then the following are "insureds": a. The Named Insured and any "family members". CA 21 50 01 11 O Insurance Services Office, Inc., 2010 Page 1 of 5 ❑ b. Anyone else while "occupying" or using a covered "auto" or a temporary substitute for a covered "auto". The covered "auto" must be out of service because of its breakdown, repair, servicing, 'loss" or destruction. c. Anyone for damages he or she is entitled to recover because of "bodily Injury" sustained by another Insured". 2. A partnership, limited liability company, corporation or any other form of organization, then the following are Insureds": a. Anyone "occupying" or using a covered "auto" or a temporary substitute for a covered "auto". The covered "auto" must be out of service because of its breakdown, repair, servicing, 'loss" or destruction. b. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another Insured". C. Exclusions This insurance does not apply to any of the following: 1. Any claim settled without our consent. However, this exclusion does not apply to a settlement made with the insurer of a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle" in accordance with the procedure described in Paragraph A2.b. 2. The direct or indirect benefit of any insurer or self -insurer under any workers' compensation, disability benefits or similar law. 3. Anyone using a vehicle without a reasonable belief that the person is entitled to do so. 4. Punitive or exemplary damages. 5. "Bodily injury" arising directly or indirectly out of: a War, including undeclared or civil war; b. Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any government, sovereign or other authority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. Page 2 of 5 D. Lint Of Insurance 1. Regardless of the number of covered "autos", 'insureds", premiums paid, claims made or vehicles involved in the "accident", the most we will pay for all damages resulting from any one "accident" is the least of the following: a. The Lint Of Insurance for Uninsured Motorists Coverage shown in the Declarations; or b. The amount of damages sustained but not recovered. 2. No one will be entitled to receive duplicate payments for the same elements of 'loss" under this coverage form and any Liability coverage form or Medical Payments Coverage endorsement attached to this Coverage Part. We will not pay for any element of 'loss" if a person is entitled to receive payment for the same element of 'loss" under any workers' compensation, disability benefits or similar law. E. Changes In Conditions The conditions are changed for Colorado Uninsured Motorists Coverage — Bodily Injury as follows: 1. Other Insurance in the Business Auto and Garage Coverage Forms and Other Insurance — Primary And Excess Insurance Provisions in the Truckers and Motor Carrier Coverage Forms are revised as follows: a. The last paragraph is replaced by the following: When this coverage form and any other coverage form or policy covers on the same basis, either excess or primary, the loss will be paid in accordance with the following method: (1) All applicable policies will pay on an equal basis until the policy with the lowest limit of insurance is exhausted. (2) If any 'loss" remains and there: (a) Are two or more remaining policies whose applicable limits of insurance have not been exhausted, then such policies will continue to pay in accordance with Paragraph (1); or (h) Is one remaining policy, then such policy will continue to pay until its limits of insurance have been exhausted. C Insurance Services Office, Inc., 2010 CA 21 50 01 11 ❑ b. The following provisions are added: (1) The reference to other collectible insurance applies only to other collectible uninsured motorists insurance. (2) If there is other applicable insurance available under one or more policies or provisions of coverage, any insurance we provide with respect to a vehicle owned by the Named Insured or, if the Named Insured is an individual, any "family member" that is not a covered "auto" for Uninsured Motorists Coverage under this coverage form shall be excess over any other collectible uninsured motorists insurance providing coverage on a primary basis. 2. Duties In The Event Of Accident, Claim, Suit Or Loss is changed by adding the following: a. Promptly notify the police if a hit-and-run driver is involved; and b. Promptly send us copies of the legal papers if a "suit" is brought. c. A person seeking coverage from an insurer, owner or operator of a vehicle described in Paragraph b. of the definition of 'Uninsured motor vehicle" must also promptly notify us in writing of a tentative settlement between the 'Insured" and the Insurer and allow us to advance payment to that 'Insured" in an amount equal to the tentative settlement within 30 days after receipt of notification to preserve our rights against the insurer, owner or operator of such vehicle. d. The following replaces the lead-in paragraph in the Duties In The Event Of Accident, Claim, Suit Or Loss condition in the Business Auto, Garage, Truckers and Motor Carrier Coverage Forms with respect to an owner or operator of a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle": We have no duty to provide coverage under this policy if the failure to comply with the following duties is prejudicial to us: 3. The Legal Action Against Us provision is replaced by the following: a. No one may bring a legal action against us under this coverage form until there has been full compliance with all the terms of this coverage form. CA 21 50 01 11 b. In accordance with COLO. REV. STAT. § 13-80-107.5, an "action" or arbitration of an uninsured motorist Insurance claim or an underinsured motorist insurance claim shall be commenced or demanded by "arbitration demand" within three years after the cause of action accrues, except: (1) If the underlying "bodily injury" liability claim against the uninsured motorist is preserved by commencing an "action" against the uninsured motorist within the two-year time limit specified in COLO. REV. STAT. § 13 -W -102(1)(d) for a wrongful death action or the three-year time limit specified in COLO. REV. STAT. § 13-80-101(1)(n) for all other tort actions to which this insurance applies, then an "action" or arbitration of an uninsured motorist claim shall be timely if such "action" is cormmenced or such arbitration is demanded within two years after the insured" knows that the particular tortfeasor is not covered by any applicable insurance; or (2) If the underlying "bodily injury" liability claim against the underinsured motorist is preserved by commencing an "action" against the underinsured motorist or by payment of either the liability claim settlement or judgment within the two- year time limit specified in COLO. REV. STAT. § 13-80.102(1)(d) for a wrongful death action or the three-year time limit specified in COLO. REV. STAT. § 13-80- 101(1)(n) for all other tort actions to which this insurance applies, then an "action" or arbitration of an underinsured motorist claim shall be timely if such "action" Is commenced or such arbitration is demanded within two years after the 'Insured" received payment of the settlement or judgment on the underlying 'bodily injury" liability claim. c. For purposes of Paragraph 3.b. above, a cause of action accrues after both the existence of the death, injury or damage giving rise to the claim and the cause of the death, injury or damage are known to the 'insured" or should have been known by the exercise of reasonable diligence. O Insurance Services Office, Inc., 2010 Page 3of5 O 4. Transfer Of Rights Of Recovery Against Others To Us Is changed by aiding the following: If we make any payment and the 'insured" recovers from another party, the 'Insured" shall hold the proceeds in trust for us and pay us back the amount we have paid. We shall be entitled to recovery only after the 'Insured" has been fully compensated for damages. However, any recovery made by us shall be reduced by our proportionate share of attorney's fees and expenses incurred in bringing the claim. Our rights do not apply under this provision with respect lo damages caused by an "accident" with a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle" if we: a. Have been given prompt written notice of a tentative settlement between an 'insured" and the Insurer of a vehicle described in Paragraph b. of the definition of "uninsured motor vehicle"; and b. Fail to advance payment to the 'insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. If we advance payment to the 'insured" in an amount equal to the tentative settlement within 30 days after receipt of notification: a. That payment will be separate from any amount the 'Insured" is entitled to recover under the provisions of Uninsured Motorists Coverage; and b. We also have a right to recover the advanced payment. 5. The Two Or More Coverage Forms Or Policies Issued By Us condition is changed by adding the following: a. This provision does not apply to Uninsured Motorists Coverage. b. No one will be entitled to receive duplicate payments for the same dements of 'loss" under Uninsured Motorists Coverage. Page 4 of 5 6. The following condition is aided: Arbitration a. If we and an 'insured" disagree whether the insured" is legally entitled to recover damages from the owner or driver of an "uninsured motor vehicle" or do not agree as to the amount of damages that are recoverable by that 'insured", then the matter may be arbitrated. However, disputes concerning coverage under this endorsement may not be arbitrated. Both parties must agree to arbitration. If so agreed, each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. Each party will pay the expenses it incurs and bear the expenses of the third arbitrator equally. h. Unless both parties agree otherwise, arbitration will take place In the county in which the 'insured" lives. Local rules of law as to arbitration procedure and evidence will apply. A decision agreed to by two of the arbitrators will be binding. F. Additbnal Definitions As used in this endorsement: 1. "Action" means a lawsuit commenced in a court of competent jurisdiction. 2. "Arbitration demand" means a written demand for arbitration delivered to us that reasonably identifies the person making the clam, the identity of the uninsured or underinsured motorists, if known, and the fact that arbitration is being demanded. 3. 'Family member" means a person related to an individual Naued Insured by blood, marriage or adoption who is a resident of such Named Insured's household, including award or foster child. © Insurance Services Office, Inc., 2010 CA 21 50 01 11 ❑ 4. "Occupying" means in, upon, getting in, on, out or off. 5 "Uninsured motor vehicle" means a land motor vehicle or "trailer": a. For which no liability bond or policy at the time of an "accident" provides at least the amounts required by the applicable law where a covered "auto" is principally garaged; b. That is an underinsured motor vehicle. An underinsured motor vehicle means a land motor vehicle or 'trailer" for which the sum of all liability bonds or policies at the time of an "accident" provides a limit that is less than the amount an 'insured" is legally entitled to recover as damages caused by the "accident"; c. For which an Insuring or bonding company denies coverage or is or becomes insolvent; d. That is a hit-and-run vehicle and neither the driver nor owner can be identified. The vehicle must hit an 'Insured", a covered "auto" or a vehicle an insured" is "occupying"; or e. Whose owner or operator cannot be located after a reasonable attempt for service of process, and either: (1) Service of process on the insurer as authorized by COLO. REV. STAT. § 42- 7-414 is determined by a court to be insufficient or ineffective after reasonable effort has failed; or CA 21 50 01 11 (2) The report of a law enforcement agency investigating the "accident" fails to disclose the insurer covering the vehicle, and the insurance coverage of such owner or operator when the "accident" occurred Is not actually known by the person attempting to serve process. However, "uninsured motor vehicle" does not include any vehicle: a. Owned or operated by a self -insurer under any applicable motor vehicle law, except a self -Insurer who is or becomes Insolvent and cannot provide the amounts required by that motor vehicle law; b. Owned by a governmental unit or agency; or C. Designated for use mainly off public roads while not on public roads. B Insurance Services Office, Inc., 2010 Page5of5 ❑ COMMERCIAL AUTO CA 24 02 12 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PUBLIC TRANSPORTATION AUTOS This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. LIABILITY COVERAGE for a covered "auto" licensed or used to transport the public Is changed as follows: The CARE, CUSTODY OR CONTROL exclusion does not apply to "property damage" to or "covered pollution cost or expense" involving property of the "Insured's" passengers while such property is carried by the covered "auto". CA 24 02 12 93 Copyright, Insurance Services Office, Inc., 1993 Page 1 of 1 ❑ Amendment Of Declarations - Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums ZURICH Policy No. Eff. Date of Pd. Exp. Date of Pol. Eff. Date of End. Producer No. Addl. Pram Return Prem. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM ITEM FOUR of the Declarations is replaced by the following: ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums Liability Coverage — Cost Of Hire Rating Basis For Autos Used in Your Motor Carrier Operations (Other Than MobNe Or Farm Equipment) Liability Coverage Estimated Annual Cost Of Hire For All States Rate Per Each $100 Cost Of Hire Premium Primary Coverage Excess Coverage T R ANY 1. 1 1 3 $ 110 Total Premium $ 1.10 For "autos" used in your motor carrier operations, cost of hire means: (a) The total dollar amount of costs you incurred for the hire of automobiles (includes "trailers" and semitrailers), and if not included therein, (b) The total remunerations of all operators and drivers' helpers, of hired automobiles whether hired with a driver by lessor or an "employee" of the lessee, or any other third party, and (c) The total dollar amount of any other costs (i.e., repair, maintenance, fuel, etc.) directly associated with operating the hired automobiles whether such costs are absorbed by the 'insured", paid to the lessor or owner, or paid to others. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 11CAA16-A CW (03-10) Page l of ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Coned) Liability Coverage —Cost of Hire Rating Basis For Autos NOT Used In Your Motor Carrier Operations (Other Than Mobile Or Farm Equipment) Liability Coverage Estimated Annual Cost Of Hire For All States Rate Per Each $100 Cost Of Him Premium Primary Coverage Excess Coverage Total Premium For "autos" NOT used in your motor carrier operations, cost of hire means the total amount you incur for the hire of "autos" you don't own (not Including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. Physical Damage Coverages — Cost of Hire Rating Basis For All Autos (Other Than Mobile Or Farm Equipment) Coverage Limit Of Insurance Estimated Annual Cost Of Hire For All States (Excluding Autos Hired With A Driver) Rate Per Each S100 Cost Of Hire Premium Comprehensive Actual Cash Value Or Cost Of Repair, Whichever is Less, Minus $ 100 Deductible For Each Covered Auto, But No Deductible Applies To Loss Caused By Fire Or Lightning $ 50,000 .950 $ 225 Specified Causes Of Loss Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Deductible For Each Covered Auto For Loss Caused By Mischief Or Vandalism Collision Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus $ 500 Deductible For Each Covered Auto $ 50,000 .667 $ 334 Total Premium $ 559 For Physical Damage Coverages, cost of hire means the total amount you Incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for any "auto" that is leased, hired, rented or borrowed with a driver. Includes copyrighted material of Insurance Services Office, Inc , with its permission. U-CA-sb -A CW (03-10) Page 2 or 5 ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) Cost Of H re Rating Basis For Mobile Or Farm Equipment — Other Than Physical Damage Coverages Coverage Estimated Annual Cost Of Hire For All States Rate Per Each $100 Cost Of Hire Premium Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Liability — Primary Coverage Liability — Excess Coverage Personal Injury Protection Medical Expense Benefits (Virginia Only) Income Loss Benefits (Virginia Only) Auto Medical Payments Total Premiums Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" rent from your partners or "employees" or their family members). Cost of hire does not include charges erforrned by motor carriers of property or passengers. you borrow or for services Includes copyrighted material of Insurance Services Office. Inc., with its permission. U -CA -810.A CW (03-10) Page 3 of 5 ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) Cost Of Hire Rating Basis For Mobile Or Farm Equipment —Physical Damage Coverages Coverage Limit Of Insurance Estimated Annual Cost Of Hire For Each State (Excluding Autos Hired With A Driver) Rate Per Each $100 Cost Of Hire / Premium Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Comprehensive Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Ded. For Each Covered Auto, But No Deductible Applies To Loss Caused By Fire Or Lightning / / Specified Causes Of Loss Actual Cash Value Or Cost Of Repair, Whichever is Less, Minus Ded. For Each Covered Auto For Loss Caused By Mischief Or Vandalism / / Collision Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Ded. For Each Covered Auto / / Total Premiums For Physical Damage Coverages, cost of hire means the total amount you Incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for any "auto" that is leased, hired, rented or borrowed with a driver. U -GA -RIGA CW (0310) Page 4of5 Includes copyrighted material of lust 'once Services Office, Inc , with its permission ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) Rental Period RatingBasls For Mobile Or Farm Equipment Coverage Town and State Where The Job Site is Located Estimated Number Of Days Equipment WI Be Rented Rate Per Each Rental Day / Premium Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Liability / / Personal injury Protection / / Medical Expense Benefits ,Vlrglnla Only) / / Income Loss Benefits (Virginia Only) / / Auto Medical Payments / / L Total Premiums All other terms, conditions, provisions and exclusions of this policy remain the sane. Includes copyrighted material of Insurance Services Office, Inc., with its permission. U -CA -816-A CW (03-10) Page 5 of 5 COMMERCIAL AUTO CA 20 02 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE - FIRE, POLICE AND EMERGENCY VEHICLES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. Physical Damage Coverage is changed as follows: A. The exclusion relating to Audio, Visual and Data Electronic Equipment in Paragraphs B.4.c. and B.4.d. of the Business Auto and B.2.c. and B.2.d. of the Business Auto Physical Damage Coverage Forms does not apply to any equipment that is in- stalled in or upon a covered "auto" which is: 1. Owned by a police or fire department; CA 20 02 03 10 2. Equipped as an emergency vehicle and owned by a political body or any of its agencies; or 3. Equipped as an emergency vehicle and owned by a volunteer fire department, volunteer res- cue squad or volunteer ambulance corps. R For covered "autos" described above, the Unit Of Insurance provision in Paragraph C.2. does not apply. Insurance Services Office, Inc., 2009 Page 1 of 1 O COMMERCIAL AUTO CA 20 18 12 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PROFESSIONAL SERVICES NOT COVERED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. LIABILITY COVERAGE is changed by adding the following exclusions: This insurance does not apply to: 1. "Bodily injury" resulting from the providing or the failure to provide any medical or other professional services. 2. "Bodily injury" resulting from food or drink furnished with these services. 3. 'Bodily injury" or "property damage" resulting from the handling of corpses. CA 20 18 12 93 Copyright, Insurance Services Office, Inc., 1993 Page 1 of 1 CI POLICY NUMBER: BAP 9474903-01 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement Identifies person(s) or organizatIon(s) who are 'Insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided In the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: Named Insured: Countersigned By: SCHEDULE (Authorized Representative) Marne of Persons) or Organtzatlon(s): ANY PERSON OR ORGANIZATION THAT THE INSURED HAS AGREED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT TO NAME AS AN ADDITIONAL INSURED AND EXECUTED PRIOR TO THE OCCURRENCE OF ANY LOSS. (If no entry appears above, information required to complete this endorsement will be shown In the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an 'Insured" for Liability Coverage, but only to the extent that person or organization qualifies as an 'Insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 D POLICY NUMBER: BAP 9974903-01 COMMERCIAL AUTO CA 99 28 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. STATED AMOUNT INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM Wth respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE i The insurance provided by this endorsement Is reduced by the following deductible(s): Vehicle Number Coverage Limit Of Insurance And Deductible Premium SEE SCHEDULE $ LIn t Of Insurance $ $ Deductible $ Limit Of Insurance $ $ Deductible $ Limit Of Insurance $ $ Deductible Total Premium $ _ NOTE: The amount shown in the Schedule or in the Declarations is not necessarily the amount you will receive at the time of loss" for the described property. Please refer to the Linmt Of Insurance and Deductible Provisions which follow. Desi jnatlon Or Description Of Covered'Autos" Vehicle Number Model Year Trade Name And Model SEE SCHEDULE Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CA 99 28 03 10 Insurance Services Office, Inc., 2009 Page 1 of 2 ❑ A. This endorsement provides only those coverages where a premium is shown in the Schedule. Each of these coverages applies only to the vehicles shown as covered "autos". B. For a covered "ado" described in the Schedule, Physical Damage Coverage — Limit Of Insurance is replaced by the following: Limit Of insurance 1. The most we will pay for 'loss" In any one "accident" is the least of the following amounts: a. The actual cash value of the damaged or stolen property as of the time of the 'loss"; b. The cost of repairing or replacing the dam- aged or stolen property with property of like kind and quality; or c. The Limit of Insurance shown in the Sched- ule. 2. An adjustment for depreciation and physical condition will be made in determining actual cash value in the event of a total 'loss". 3. If a repair or replacement results in better than like kind or quality, we will not pay for the amount of the betterment. Page 2of2 C. Deductible 1. For each covered "auto", our obligation to pay: a. The actual cash value of the damaged or stolen property as of the time of the *loss" will be reduced by the applicable deductible shown in the Schedule; b. The cost of repairing or replacing the date aged or stolen property with property of like kind and quality will be reduced by the ap- plicable deductible shown in the Schedule; or c. The damages for 'loss" that would other- wise be payable will be reduced by the ap- plicable deductible shown in the Schedule prior to the application of the Limit of Insur- ance shown in the Schedule. 2. 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F@ c E Qg E ^o g ` in �vR �qq y c s `t iwa 5141 o Ol $i=Q E 8-.2 gif 76 2.444 a K=o �� .a gtl3 g�� &IiIZ ¢" o ff' E" g't2 a tt c HSte �� 2oY 8 a Yllu}ilflufth .n !�' a^ o 8n $E y $ v flildiffi fiF°�53:Y3F� �l DR,Qag i • �til�'E'E �g g8g 111d Ric eh'U a aalYtiht.�t s9. $$ f f, 4a g f {p ja.§ C d L x p o8saa 2.6i4 allYil ?I 4i3 $vA 6 w E 2 ;Y Y 41 e H 'C O n 60 hi aes S y¢i n F lilt shish 1441 4S i S 4 a sass 0000 ?8 =a am2771e N . S 8q O I EMT/EMT-BASIC 201J **IMPORTANT - PLEASE READ** Dear EMS Professional: According to our records your National EMS Certification is due to expire on March 31, 2013. By offering a nationally uniform process for maintaining your EMS credential, we are helping to assure the maintenance of the necessary skills and knowledge required for competent EMS practice. In addition, you are displaying your commitment to assure the safety of the public and the patients you serve. Note: if this is your first recertification you must be actively working within an emergency medical service or patient health can facility using your appropriate EMS skills, or provide proof that you have performed the duties of an EMS provider for at least 6 months. It is very important that you carefully read the instructions provided within this packet. The NREMT considers recertification to be an individual responsibility. If you expect your employer to complete and submit the recertification paperwork (including payment), and they fail to do so, your certification will lapse. We are depending on you to take personal responsibility to complete this process. Individuals requiring a National Registry Card to work must submit recertification materials to the NREMT for processing by February 15 of the year your card expires. The NREMT offers three options to recertify; we encourage you to use our online recertification process, which allows you to 'bank' your continuing education throughout your certification period. The online recertification uses electronic signatures (including your Training Officer and/or Medical Director). Online recertification does not require you to mail any documentation, however we encourage you to keep your documents as part of your personal files. The NREMT does perform random audits of recertification applications and that documentation may be necessary to verify your continuing education. Recertification options: Online Recertification (at www.nremt.org) 1. Login in to your NREMT account (if you don't have one, you may establish one using 'Create new Account' located in the upper left hand column). 2. Affiliate with your Agency (employer) by clicking on 'Unaffiliated' and following the online prompts. 3. Use the 'Manage Education' to enter your completed continuing education. 4. When you have completed all your continuing education, submit the records electronically to your Agency/Medical Director for verification. If your Agency is not registered on the NREMT website, you may print the form and obtain the required signatures. Mail the completed, signed form, application fee and required documents to the NREMT before March 31, 2013. 5. The non-refundable application fee of $15.00 is due with submission. If you are printing and mailing the form, you may enclose a check with the completed, signed form and the required documents. 6. Your application submissions and all applicable fees must be completed by March 31, 2013. Complete the 2013 Recertification Forms enclosed 1. Follow the enclosed instructions. 2. Obtain signatures on the form, attach a copy of your refresher certificate and CPR card and verifying signature and; 3. Enclose the $15.00 non-refundable application fee (check or money order) and; 4. Mall the form, application fee, and required documentation to the NREMT address below, before March 31, 2013. Recertify by Exam 1. Establish an account on the NREMT website at www.nremt.org and complete a recertification by examination application and pay the $70 non-refundable exam fee. 2. Monitor your account for your Authorization to Test letter that will appear when you log -in and click "Check Recertification by Examination Application Status'. Follow the directions on the letter to schedule your exam_ 3. Take and pass the exam before March 31, 2013. Upon success, you will receive an abbreviated recertification form from the NREMT. 4. Return the abbreviated recertification form by March 31, 2013 with signatures and supporting documentation. 5. Remember that you will have one attempt to successfully pass the recertification by examination test. If you are unsuccessful on the test, you can still recertify online or by paper before the March 31° deadline. Mall recertification documentation to: (Use preprinted mailing label provided) National Registry of EMTs 6610 Busch Blvd Columbus, ON 43229 All documentation MUST be postmarked to the National Registry office by March 31, 2013. When mailing your documentation, it is recommended that you submit recertification material by traceable or delivery confirmation means. If you fail to submit your recertification by the March deadline, you may seek re -instatement of your NREMT credentials until April 30, 2013. You must complete the recertification form and attach your check or money order totaling $65.00 ($50 re -instatement fee and $15 processing fee). All educational requirements must be completed by March 31, 2013. If you do not submit the form prior to April 30, 2013. your National Registry Certification will lapse. NREMT does not provide extensions of recertification applications. EMTaEMT-aASIC 2013 Please allow 4-6 weeks for recertification to be processed. If you do not receive your Registry card or your recertification form is not returned by May 15, 2013, you should contact the National Registry at 1314-888-4484. It is our pleasure to serve you and we look forward to your recertification application arriving soon. FOR YOUR RECERTIFICATION TO BE PROCESSED, YOU MUST COMPLETE THE RECERTIFICATION FORM IN ITS ENTIRETY. INSTRUCTIONS REFRESHER TRAINING: • Submit a copy of your course completion certificate of 24 hours refresher training, adhering to the content of the COT/National Scope of Practice Refresher Training. If a formal refresher course was not completed, the refresher Section must be completed through continuing education hours, ensuring you have met the mandatory core content during this recertification cycle. You may complete up to 10 hours of the refresher course through distributive education provided your state EMS office approves the program or they ere CECBEMS approved. CPR CERTIFICATION: • CPR certification that is current and valid on the day the NREMT receives your form. You may submit a copy of your CPR card or have a verifying signature along with EMS Professional's expiration date. ADDITIONAL EMS RELATED CONTINUING EDUCATION: • 48 additional hours of EMS related continuing education. • This section must be completed in its entirety, listing by date, topic and total number of training hours received and annotate how the education was delivered (lc, classroom, in-service training, video training, computer etc.). If completed through distributive education you must include the approval number from CECBEMS. You may accrue no more then 24 hours towards this section from distributive education, and must be approved by CECBEMS or your state. For a listing of approved programs go to %woo CECBEMS.org. AN continuing education must have been completed within the current certification cycle (April 1, 2011 - March 31, 2013). If this Is your first recertification, only continuing education completed after the date of Initial certification will be accepted. VERIFICATION OF SKILL COMPETENCE: • Verification of EMT/EMT-Basic skills on this document by the training program director or service director (original signatures are required on the form). • Competence may be verified through any of the following three methods: quality assurance or quality improvement programs; direct observation of the skills being performed in an actual setting; or other acceptable means of skill evaluation. APPLICATION FEE: • $15.00 application fee (non-refundable) will be charged for each appication submitted for consideration of recertification. • Make check or money order, payable to the National Registry of EMTs. U.S. funds only (please write registry a on all checks). • NREMT accepts credit card payments when using the online recertification options. Please print and attach a copy of the online payment receipt • A 530 fee will be assessed for all returned checks. APPROVING SIGNATURES: • The Training Officer/Supervisor must sign the form after reviewing the EMS Professional's refresherlcontnuing education. The EMS Professional cannot verify his/her own activities/Stills. • Applicant should obtain all the necessary signatures before submitting the application. INACTIVE STATUS • Is for current, Nationally Registered providers who are not actively working in an EMS service or performing with en agency that provides direct patient care at the time of application/recertification. • Those recertifying during their first recertification cycle end requesting Inactive status must provide official widen documentation of a minimum of six months' affiliation at the appropriate level. AUDITS & FRAUOULANT SUBMISSIONS • NREMT will complete random audits of activities documented on this form. • Inaccurate verification or submission is a serious violation of National Registry standards Mat may lead to revocation and/or other action as deemed appropriate by the National Registry. Since certification is designed to help assure the pubic that EMS Professionals are competent to deliver care, EMS Professionals and Training Officers must take seriously their responsibility in meeting and documenting recertification requirements. • NREMT will report any and all cases of falsified documents to the EMS Professional's State EMS office for potential state action. PROCESSING TIME • Please allow 4-6 weeks for your recertification application to be processed. If you have not received your Registry card and your application has not been returned by May 15, 2013, please contact our office. RESPONSIBILITIES OF SUBMISSION • Recertification is considered an individual's personal responsibility. • It the EMS Professional expects their employer to complete and submit their application and associated application fee, and the employer fails to do so, your certification will lapse. INCOMPLETE FORMS/SUBMISSION • Incomplete recertification forms will be returned to the listed address and must be returned to the NREMT within 30 days with the required corrections, in order to be processed. • Form completion and submission is the applicant's sole responsibility. LATE SUBMISSION OF APPUCATIONS • If you fail to submit your recertification by the March expiration date, you may seek re -instatement of your NREMT credentials until April 30, 2013. • You must complete the recertification form and submit a $65 application fee ($50 re -instatement fee and 815 recertification processing fee). • If you do not submit the form and required processing fees by April 30th, your National Registry Certification will lapse. THE NREMT does not provide extensions of the recertification date. MAIUNG FORMS • The NREMT recommends you submit your application utilizing a traceable or verifiable means of delivery confirmation. ALL RECERTIFICATION MATERIALS MUST BE COMPLETED AND POSTMARKED NO LATER THAN MARCH 31, 2013 PLEASE MAIL RECERTIFICATION MATERIALS TO: NATIONAL REGISTRY of EMT, 8810 BUSCH BLVD (Use preprinted mailing label provided) COLUMBUS, OH 43229 www.nremtorg C a) a) L C/J -o co O a) 0) a) E W a) a) O 4) O I cn a O .V .Q a -c N. O C N N N N N (Q a a a) 'a) o o 2 z I r- 65 g Q N i co O y E r TC A co CO "0 V aicfl H 2 co Cl) N a) -o or _ C Opens for Business on Nov. 26th a THE NATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS EMT - Basic Recertification Form 2013 Registry Number Last Name Mailing Address City Email B Please read Instructions enclosed Social Security Number First Name I a_ State Zip + 4 Home Phone Area Code Mid. lnit. FELONY STATEMENT YES O NO O Since your last certification, have you been convicted of a felony? YES CA NO O Since your last certification, have you ever been subject to limitation, suspension from, or under revocation or probation of your right to practice in a health care occupation or voluntarily surrendered a health care licen- sure in any state or to any agency authorizing the legal right to work? 11 you answered "yes" to either question, you must provide official documentation that fully describes the offense, current status and disposition of the case. If yew employer requires you to maintain your National Certification, you must submit your recertification materials by Februry 1581 of the yes your card expires. EMPLOYER INFORMATION Organization in which you currently serve as/are employed as an EMT -Basic: Agency: Address: City State Zip Code Training Officer Daytime Phone # RY ccmp'et,n5 In's section you am indicating you am cuiren y pertormiro 1 M r•iiasic Ski is r either the emergency ambulanceeescue or patient/health care setting. INACTIVE STATUS REQUEST ET) Request inactive status' If this Is your first time to recertify, you must have worked at least 6 -months performing as an (EMT -Basic) and using your skills in either the eme'- gency ambulance/rescue or patient/health care setting. You will need to submit proof of employment. TRANSITION STATEMENT YES O NO O I have completed all of my state's requirements for the EMT -Basic to EMT transition. FOR OFFICE USE ONLY (is) ( A ) ( a ) ) (50) ( a ) C2) CD ( 3 ) ( a ) (to. ) ( J 3 r.o. 0u) CiD Ce') EMT BASIC REFRESHER TRAINING - (24 HOURS REQUIRED) Division Dates Firs Firs Method Completed Req Rec Used Preparatory Airway Pt. Assessment 2 3 Medi/Behavioral 4 Division Trauma Dates Hrs Hrs Method Completed _ Req Rec Used 4 OB,Ints & Child 2 Elective TOTAL HRS 8 24 • Send copy of your course completion certificate from state approved EMT Basic Refresher. It a formal refresher was not completed, fill out this section completely, applying continuing education dates, hours and method used In the appro- priate areas above and enclose copies of course completion certificates or official letter of verification (documents submitted will not be returned). CPR CERTIFICATION As the EMS Professional's CPR Instructor/Training Officer, I hereby verify the EMS Professional has been examined and performed satisfactorily so as to be deemed competent in each of the following: Adult 1 & 2 Rescuer CPR Child Obstructed Airway Adult Obstructed Airway Infant CPR Child CPR infant Obstructed Airway CRR Instructor/Training Officer Verifying Signature Submit copy of card AND/OR verify with approprlste signature_ MonthYear EMT'a CPR EXP DATE National Registry of EMTs • 6610 Busch Blvd • Columbus, OH 43229 Pago 1 www.nremt.org yyADDITIONAL Teplrpt EMS RELATED CONTINUING ti q�Illutt�( EDUCAUON futsktlt tiblt p pct tit - (48 tNF• HOURS REQUIRED) u ; ,n. opialn baiei g x t llal tc on TOTAL HOURS VERIFICATION OF SKILL COMPETENCE O/A: 0/I Direct Observation Other 1. PATIENT ASSESSMENT/MANAGEMENT: Medical and Trauma 2. VENTILATORY MANAGEMENT SKILLS/KNOWLEDGE: Simple adjuncts Supplemental oxygen delivery Bag -halve -Mask One -Rescuer Iwo -Rescuer 3. CARDIAC ARREST MANAGEMENT: Automated External Defibrillator (AE0) 4. HEMORRHAGE CONTROL 5 SPLINTING PROCEDURES 5. SPINAL IMMOBILIZATION: Seated and lying patients 6. OB/GYNECOLOGIC SKILLS/KNOWLEDGE 7. OTHER RELATED SKILLS/KNOWLEDGE: Radio communications Report writing & documentation As the EMT -Basic Training Director/Service Director, I do hereby affix my signature attesting to continued competence in all skills outlined above. Signature of Training Director/Service Director Title (must be original signature) Date Signed I hereby affirm that all statements on the EMT -Basic Recertification Form are true and correct, Including the copies of cards, certificates and other required verification. It is understood that false statements or documents may be sufficient cause for revocation by NREMT. It Is also understood that NREMT may conduct an audit of the recertification activities listed at any time. Your Signature (must be original signature) Date Signed Signature of Training Officer/Supervisor (must be original signature) Page 2 Date Signed Hello