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<br />'11/28/2007 11:05
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<br />18137156697
<br />
<br />NUTRICIAN
<br />
<br />PAGE 03/03
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<br />CERTIFICATE 01<' CO",7EMGE Tssue Date: 06/0Jl2oo7
<br />Adventist Haith System This certificate is issued as a IlIlltter of il1formBtioll nn Iy and confers nO ri ghLS
<br />Dept. of Risk M:l'lagcmcul &. J,n~urancc: llpon thc Certificate Holder. This =tifieale c10cs I1011lmcnd. extend or alter the
<br />111 North Orllllldo Avenue C(\vcrage lIfforded by the self in~un:d tr\Ist or any insurance policies listed below.
<br />Winter Park, FL 32789 407-975.1420
<br />Named PlIrticlpBDt: COMPANIES AFFORDING COVERAGE
<br /> cmiiiiiI", .Letter A: MIS 1.iabllTIV Selr 1n,,!1IftCC TNs!
<br /> COIll1l...... Letla' B. ADHcallll-lI!.ncI\11'111ce
<br /> Cft_m Leuer Co ADHc>>lII (A\Red World AmJr:mCC C""'....nvl
<br /> Comn~- Letter 1); ADH~Is..;u~)
<br /> " CmnDll1lY Letter E: LibertY MUll110l Fire 1nJ~ CO....IIIIV
<br />Florida Hospital Zephyrhills. Inc. eem.DT J..eUer 1: PlQricb HMftI..' SCIr.Fundod Worlccr's CanIIlelISlllion I'IG""''''
<br /> 0.-:1,", J.,r.IIer G. ASS SeIr.fuDded Worka's Ccm1lellJlltlcm Premm
<br />7050 Gall Boulevard CmIlDlm,. J~lltr H: Ml~,I>_""'-'
<br /> Com""- T..eUer x: Unlll:ll WdcClllPn 1fts\InIIcc CariiII:lIl,.
<br />Zephyrhills, FL 33541 Ca......",. Lettu' I. cmraBIElo;c=atiYc lUsk l.......il'l
<br /> Co_Ill' Leder X' ?;arieh Amerton 1IWI\'lIDCe ~
<br /> Co.....81l. Lctrr.r J.: ZlIricb Amo:ric2II W\Ir1Ifla: C"""'_
<br /> o._DY LdJer III: wlli",(WIIDs_l:anmoIw
<br /> CM-:l....I,dkrN: UIW.l',c>fLcllldon
<br /> -CtmID:IMJ",,_ 0. AJch ~~lV ln5nnmco ComallJl'l
<br /> cOiii1ii",. J,etta'1': l.lIndmri AIIIerlcom In:uruce Co........"
<br /> eo_ LeUH' Q: ^DRc:llLb
<br />COVer81!eS
<br />'Pus is to certify t.!I:It eovcnl:l' d(Clmcnts lJ$lCd below 1I:I,.c been iJS')C(l1O lhc Named P/lI'IIelpllDI Ji~led above (or thc Dmo period indiC2lted. Nll<<Wit/lst:\lldlng any reIlUlrclllCD1, lcrm or condition of
<br />:\llY eonttact or other doc:mncDt "';111 I'I:SpCC:I 10 wbich tl!i~ c:cnlfiCllII: JIlI)Y 110 lUlled or rray pertain. tlle lnsurnncc ~ffordcd by !he polidc$ described m:re;nls subjccI10 all the tcm\<, excluJiClft$, :IIId
<br />condltiom of sud\ ~llclcs. Limir.~ ,<IIown lJlIIV have been relIllc:cd bv mid clnims.
<br /> Co rol\cJ Bll\diyt Pole, Explnt11nD T..inlilS
<br /> Ltr ~'otJ_rIlllCl! I'ftII....N"mbe.. Dlolr. Dnte
<br /> A X Hosp, ProfJCamprCIICllJlw 0C:\ICfIl1 Unbility A Jlbnp 85?-3.:2007 ()4IlI1120ll7 DilIOl/2008 BRch OClODnalCC $15.000.000
<br /> CIrc bro'l< &. OlIli!llonl'
<br /> B " lJ"'JI. PlOr./ConlJlrellcnSiI/C Gcnernl Li~lIlty IlL M.....p1 oo7047~-005 ool101nll1/7 04l0l/?llOB A~""'ll"le $2.S.00o,(Illll
<br /> c.n. Bn-ars &. OmlJPlcms
<br /> C X H~ l'rOf.lComJm:ht1lSl.... G:ner:d UMlli", & MlI"tCd ClIll:zs6~J004 04/0112007 ~IOII2OllS AIW"lP1e S2S,Ooo,OllO
<br /> 0= ElftlrS &; OmimOllS
<br /> p X 'If""" 1'rDr~:i.." C'..cnctnI UabllllY IlL MlInaBCd MHJlt98.2 (1410112007 O'lIOlanDS A!!Jt!C~nte 51S.000,OOlI
<br /> c;.n, ~ &. Oml~an.~
<br />NBlCIO " I ClSIII!I MLNlc (HP1. & M"""p CIrc Emm;)
<br />AlSICIO X I ();cnneneC (CGJ~ Only)
<br />"F.! X All\O"",lnlc Li:lbUlty. /l.n vahiclCi AS2-6.S1-28G53S,Ol"7 0110 112007 OI/O\/2DllB Combined Slow" Limil $\ ,000,000
<br /> ~llCi:l;:'~jwy &J'mpcny
<br /> DlI1I1l'
<br />P X Worker' J CmapetI::ulOD l'1odda Irasp'''' - Oriftllllo F1iWC07 otIIO lFJUJ7 O6IOlI?OOR Stan'l(lY}' Limits $1.000.000
<br /> ond .._I-sl,.iAbilil'\l 1'na1iti~
<br />G X Warter's Cocnpc:c.:uillll l"lorid~ DMJlon AltSWCOi OfilDll2OO7 06lO11200~ Sumltory Limic 51.000.000
<br /> :md l!IftpIoycr' s J..lAbiliLy PllCili~ 3Ild all Olbcr I
<br /> SlDtCS Bll""'" Tcx:ll:
<br />H X War1="s CoIlIpelISIIGlI1l CO. Pf_ GA. n. KS. KY. EWCOO7923 oGlO ll2007 06Jll112Oll8 iilOtllllllY Umlts $1.000,000
<br /> 3IIdi;"",lavcr'. LilIblUtv NC. TN
<br />JJ X WlJlkl:r'8 CcmpaIsallD'l Tc:nDeSIlCC ^JW1'!l"lC EWCOO75!1t1 0610112007 06101/2008 SlIllll1my Limits
<br /> :wi !IllDIm/cr'. LiabilllV
<br />I X Work1:r'~ ~tll'I' ChippewA :HDlIJ'it.>l 04DOllGZ'I!l~ 1 l/O~1200G lIJ04I1.1lO7 S'"b1Iory LiDU
<br /> anti"Bm.;lo.....'. Li:lbiU",
<br /> """""'" 8t omem:
<br />J X PrimAty Plllicy &161-94?5 O6IDII2OOG 09101J1Ql17 Sl S,OOll,DOll
<br />X " &ccs:; I'DIicy S2391Z'1.01 0610112006 091011.llI07 $10.00lI.DOD
<br />J X PkIc1Jty B167-9438 OfilDI12OO6 0'J01J?OO7 :>IO.Ol1O.DOll
<br />J X F1duclnry 8167.940\0 06ID 11.llI06 0910112007 $10.000,0l\ll
<br /> Propeny nncl ~~:
<br /> Priaury Polley (QuO'" Sb.....)
<br />L X ~1riclI ZMD 370565605 0110]12007 01101I2OOB }
<br />M X l..c:ltIlJJ!fGJI 16062!18 01/0112007 OIIOI/2lIlIR :;'7511,000.000
<br />N X Lloyd" ofLatldOll 0l'SS0607 01 Jtlll2DD7 0110112008
<br />0 X Atcb SpeciAl", 1tt<UrnIICC C"""'''''>' PRl'OOI9SR6-00 0110112007 01/0\12008
<br />6 X I'll':( Exec.. Loyer L"RO~SD233 OllOl12DD7 01/0112008 USO.DOll,OOO
<br /> X SeellIId :Ell....... L/ntcr AIJS2II07.o1 01/0\ I2Oll7 0110\/21108 51.700.000.000
<br />Descrlption Or OperationtllLoc:ation$IVebldeslSpeclalltems:
<br />All opcraIiOllS subjea to the tcnnS a'Od conditions ofthc Trus1 orinsuDnce policies listed above,
<br />Coverage -prollided is;l per oeeurrencc aggregate and is no1 iJlcreased by the number ofn:uncd participants or c:Jaimants illvOlVI:I!.
<br />C<<'lftcalt Hllldl!l' Omozll:s\llln
<br /> Sbot.)d "DY of tile ;Illove described rollclcs be QlJleelled before !be lCOfllr:nion dla: 11lerc:01. llIc jS$1liDI
<br /> company wlll coliCIn/or lD mail wrillCft notice lO !he Ctttincall: Boltler IIllmcd 10 !be lcoft., !nit mill'''' 10
<br />Florida Hospital Zephyr-hills m:liJ ,..cl'l nollec sbAII impose no oblif!l'tion at lIabilil)' <,If ~ny Idnd IIpOII t.hc CDmpllny, il$ ~RCIIb ar
<br />Yelll'C!CDrntiVd or cnmJo"""",,
<br />7050 Gall Boulevard ^.thorjad~tlllll~~
<br />Zephyrhil1s, FL 33541 p~~ ~-
<br /> D:Itt: 06lO1IlOll7
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