HomeMy WebLinkAboutInvoices - BOCCMartin -Morris envy
105 Basin St NW
PCS Box 1000
Ephrata, WA 98823
Morgan Scott Fife
35 c St. N
Ephrata, WA 98823
Ca
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rPolicy#IJG931001A06/17/2021--06/17/2022
Risk Placement Services
190369
06117/2021
Renew policy
Professional Liability - 2021-2022 Renewal w dl
45,000.00
Policy Fees & Taxes
2,578.60
Due Date: 7/2/2021
Dated this day of 9 20
Board ofC,ounty Co issioners
Grant C=ounty, Washington
goys DisVp Abstain
Dist #1 Dist # l � Dist # l
Dist #2 49> Dist # 2_-- Dist # 2
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Bast # Dist # 3 Dist # 3
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https://martinmorris.epaypolicy.com/
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06/17/2021
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GeneralStarTM
General Star Indemnity Company
1 N. Wacker Drive, Suite 800
Chicago, Illinois 60606
BINDER — GENERAL STAR SPECIAL RISK PLUS
PHYSICIANS & SURGEONS PROFESSIONAL LIABILITY
NOTICE: THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS STATED
HEREIN. READ THE ENTIRE POLICY FOR TERMS, CONDITIONS, COVERAGES, LIMITS, ETC.
In consideration of the payment of the premium and in reliance upon the statements and representations in the
insured(s) application(s) for this insurance, we provide insurance per the terms of the policy, which consists of
coverages as stated below:
BINDER ISSUE DATE: 06/16/2021 1 BINDER NUMBER:B-931 001 A
BROKER: RPS HEALTHCARE TAMPA BROKER ID: 0007A331
NAMED INSURED: S Fife, MD Morgan APP ID: 2352964
F --y I
BUSINESS ADDRESS: 1800 SOUTH CLOVER DRIVE
Moses Lake, WA 98837
MEDICAL SPECIALTY: Correctional Medicine
Specialty Code: 85102
EFFECTIVE DATE: 06/17/2021 RETROACTIVE DATE: 05/18/2015
EXPIRATION DATE: 07/17/2021
12:01 a.m.. Standard Time at Insured Location
Note: Binder expires on the date stated above; not on the annual policy expiration date.
LIMITS OF LIABILITY: $1,000,000 EACH CLAIM/ $3,0009000 ANNUAL AGGREGATE
CLAIM EXPENSES:
X a. Are included within the limits of liability.
b. Are not included within the limits of li_ability_
DEDUCTIBLE: $10,000
X a. The deductible amount specified above applies to both Damages and Claims Expenses.
b. The deductible amount specified above applies only to Damages.
ANNUAL PREMIUM: $45,000 SEE RPS INVOICE FOR FULL AMOUNT .DUE
25% Minimum Earned Premium applies; no flat cancel.
PERCENTAGE OF FULL ANNUAL PREMIUM FOR 12 -MONTH EXTENDED REPORTING PERIOD:
100%
PERCENTAGE OF FULL ANNUAL PREMIUM FOR 36 -MONTH EXTENDED REPORTING PERIOD:
150%
PERCENTAGE OF FULL ANNUAL PREMIUM FOR 60 -MONTH EXTENDED REPORTING PERIOD:
200%
Continued on next page '*
PAGE I OF 2
Coverage provided by this Binder and by the policy, if issued, is underwritten by the GENERAL STAR
MANAGEMENT COMPANY identified above, on a surplus lines basis. Your insurance agent or broker
can answer questions regarding your surplus lines coverage.
-- -----------
This Binder may be canceled by the Insured by surrender of this original document to the Company, or
by written notice to the Company stating the effective date of the cancellation. This Binder may also be
canceled by the Company, prior to its expiration date, by providing notice to the Insured. This Binder is
automatically canceled when replaced by a policy. If this binder expires prior to being replaced by a
policy, the coverage provided by this binder expires upon the expiration date stated above. In any event
of cancellation or expiration, the Company is entitled to charge a premium for the binder, including the
Minimum Earned Premium as stated hereon.
Date Issued:
06/16/2021
PAGE 2 OF 2
Authorized Signature:
Liana Tufariello