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CERTIFICATE HOLDER: D
WELD COUNTY HEALTH DEPARTMENT
MEDICAL STAFF OFFICE
1555 N 17TH AVE
GREELEY CO 80631-9117
NAME & ADDRESS OF INSURED:
Cynthia A. Burns, M. D.
Grosboll Clinic, PC
232 West 4th Street
Loveland, CO 80537
CERTIFICATE OF PROFESSIONAL LIABILITY INSURANCE:
This Certificate is issued as a matter of information only and
confers no rights upon the holder. By its issuance the Company
does not alter, change, modify or extend the provisions of
said policy and does not waive any of its rights thereunder.
POLICY NUMBER: CRF870057 RETRO DATE: 07/01/2000
POLICY PERIOD: 2001/03/01 TO 2002/03/01
LIMITS OF LIABILITY:
Per Medical Incident: $1, 000, 000.
Annual Aggregate: $3, 000, 000.
SPECIALTY: Internal Medicine-N.O.C./03
CANCELLATION:
Should the above described policy be cancelled before the
expiration date thereof, the issuing company will endeavor to
mail 30 days written notice to the above named certificate
holder, but failure to mail such notice shall impose no
obligation or liability of any kind upon the company.
Dated at: Denver, Colorado Date: February 16, 2001
CountersP4f7ed Authorized Representative
CIC-0004A (6/82)
2001-0624
Post Office Box 17540 Denver, Colorado 80217-0540 (720) 858-6000 1-800-421-1834 FAX (720) 858-6001
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