HomeMy WebLinkAboutN R ADD - INSURANCE - 2/11/2011A� Rom® CERTIFICATE OF LIABILITY INSURANCE
DATEiMMM)D YYY)
THIS CERTIFICATE`18 ISSUED AS A MATTER OF iINFORMATION 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.HOL'DER.
IMPORTANT! If the certificate holder Is an ADDITIONAL INSURED, the policylies) must be:endoreed. If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certaln ,policles may require an endorsement. A statement on this certificate does not confer rights to the
certificate; holder InMawof such endorsement(s).
PRODUCER
SteveBasler State Farm InsurancePHONE
3994 Youngfield' St
Wheat Ridge, CO. 80033
Office# 303-421 w8300 Fax# 303-421-8302
NRIJACT STEVE BASLER
LA& Nm • 303-421-8300 (A c No): 303-421-8302
ADDRESS: STEVE@HELPINGPROTECTYOU:COM,
PRODUCERCUSTOMER,p 0: 062410
INSURE S AFFORDING COVERAGE
NAIC 0
INSURED
PREMIUM SOURCE INC
i o,35PEARL ST Al,31'1
BOULDER, CO. 80302-5130
INSURER A: State Farm Fire and'Casualty Company
'25143
INSURER 0:
INSURER C :
INSURER 0:
'.INSURER E : -
INSURER F : -
COVERAGES CERTIFICATENUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THEPOLICIES 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
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 BEENIREDUCED BY PAID CLAIMS.
INSR
L•TR
TYPE OF INSURANCE
D
BR
POLICY'NUMBER
POLICY EFF
MIDDIYYYY '
POLICY EXP
MMID IYYYY
LIMITS
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
01101/2011,
0110112012,
EACH OCCURRENCE
S 2,000,000
PREMISES IEa occurrence)
EIF]$8K2
MED EXP.(Any one person)
S 500,000
PERSONAL & ADV•INJURY
S
GENERAL AGGREGATE
E 4,000,000
GEN'L AGGREGATE,LIMIT. APPLIES PER:
POLICY -'PRO- 'LOC
J CT
PRODUCTS- COMP/OP AGG
S 4,000,000
.3
'AUTOMOBILE'
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS'
HIRED AUTOS
NON -OWNED AUTOS
❑
❑
COMBINEDSINGLE'LIMIT
(Ea accident)
E
BODILY INJURY (Per person)
S
BODILY INJURY (Per accident)
:S
PROPERTY DAMAGE
(Per accident),
$
S
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
❑
❑
--EACH
OCCURRENCE---
-5.�.
AGGREGATE
S
DEDUCTIBLE
RETENTION - 'S
S
S
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN,
ANY PROPRIETOR/PARTNER/EXECUTIVE a
OFFICER/MEMBER EXCLUDED?
Mandatory in NH)E.L.
if yea, describe under
N I A
❑
WC STATU- OTH-
LIMITS ER
E.L. EACH ACCIDENT
S
DISEASE --EA £MPLOYE
S
E.L. DISEASE - POLICY LIMIT
S
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES ,(Attach ACORD 10% Additional Remarks Schedule;if more space is required)
1035'IPEARL ST 9311 BOULDER, CO: 80302-5130
23-OLD TOWN SID STE 34 FORT COLLINS; CO. 80524-2473
SHOULD ANY OF THE ABOVE '!DESCRIBED POLICIES BE CANCELLED '!BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE,
STEVE BASLER
01988. 2009 ACORD CORPORATION. All rights reserved:
ACORD 26 (2009/08) The ACORD name and logo are registered[marks �9j ACORD p 1'001488 132849A 02-11-2010