HomeMy WebLinkAboutL & M UNDERGROUND INC - INSURANCE CERTIFICATE 2022-2023DATE (MM/DDIYYYY)
ACOR� CERTIFICATE OF LIABILITY INSURANCE
�� 12/21/2021
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 policy(ies) must have ADDITIONAL INSURED provisions or 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 CONTACT
NAME: Daniel Glascock
Commercial Risk Solutions PHONE Fax
6600 E Hampden Ave Ste 200 a�c r,o eXc : 303-996-7801 aic No : 303-757-7719
Denver CO 80224 ADDR�ess: dglascock@crsdenver.com
INSURER(S) AFFORDING COVERAGE NAIC #
iNsuReRa: Westfield Insurance 24112
INSURED L&MUN-1 INSURER B: PIIlIlBCOI ASSUf81lC@ 41190
L & M Underground, Inc.
7529 S. Storm Mtn. iNsuReR c:
Littleton CO 80127 INSURER D:
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER:306320473 REVISION NUMBER:
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 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 BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICYNUMBER MM/DDIYYYY MM/DDIYYYY
A X COMMERCIALGENERALLIABILITY Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $1,OOQ000
DAMAGETO RENTED
CLAIMS-MADE %� OCCUR PREMISES Ea occurrence $ 500,000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $2,000,000
X POLICY � jE � � LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILELIABILITY Y CMM4932062 1/1/2022 1/1/2023 COMBINEDSINGLELIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
A X UMBRELLALIAB X OCCUR Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $10,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED X RETENTION $ $
g WORKERSCOMPENSATION Y 4025271 1/1/2022 1/1/2023 X PER OTH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $ 1,000,000
OFFICER/MEMBEREXCLUDED? N NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPER4TIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
A Leased/Rented Equip CMM4932062 1/1/2022 1/1/2023 Limit 250,000
Deductible 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Fort Collins and CDOT are included as additional insured for ongoing and completed operations on the General Liability and included as additional
insured on the Auto Liability with respect to operations of the named insured for the certificate holder as required by written contract. Umbrella Liability follows
form on the General Liability with respect to the additional insured. Workers Compensation coverage includes a waiver of subrogation. General Liability policy
has been endorsed to provide (30) days notice of cancellation except 10-day notice for non-payment of premium.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Division
215 North Mason Street, 2nd Floor
P O BOX rJSO AUTHORIZED REPRESENTATIVE
Fort Collins CO 80522 ����
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXPANDED ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
The coverage provided by this endorsement is summarized below and is intended to provide a general
coverage description only. For the details affecting each coverage, please refer to the terms and condi-
tions in this endorsement.
A. Who Is An Insured broadened:
• Additional Insured by Contract, Agreement or Permit
• Legaily Incorporated Subsidiaries
. Newly Acquired Organizations
B. Supplementary Payments
• Bail Bonds - $5000
• Loss of Earnings - $500
C. Fellow Employee Exclusion Amendment
D. Coverage Extensions
• Transportation Expenses
• Personal Effects (Excess Basis)
E. Additional Coverages
• Expenses paid for returning a stolen covered auto
• Fire Department Service Charge
F. Airbag Coverage - Accidental Discharge
G, Glass Repair - Waiver of Deductible
H. Knowledge and Notice of an Accident, Claim or Suit
I. Unintentional Failure To Disclose Hazards
J. Worldwide Coverage
K. Definitions
• Bodily lnjury Redefined
In addition to the policy amendments contained in A. through K. listed above, the endorsements listed
below will automatically be attached to your policy to complete the coverage provided by the Business
Auto Expanded Endorsement:
• Audio, Visual and Data Electronic Equipment Coverage Added Limits - CA 99 60
• Auto Loan/Lease Gap Coverage - CA 20 71
• Drive Other Car Coverage - Broadened Coverage For Named Individuals -(Executive
Officers/Spouses) - CA 99 10
• Employee Hired Autos - CA 20 54
• Employees As Insureds - CA 99 33
• Hired Auto Physical Damage (Refer to Auto Declarations page)
• Rental Reimbursement Coverage - CA 99 23
• Waiver of Transfer of Rights of Recovery (Waiver of Subrogation} - CA 04 44
A. WHO IS AN INSURED BROADENED
SECTION II - COVERED AUTOS LIABILITY
COVERAGE, item A. Coverage, 1, Who Is An
Insured is amended to include the following
additional paragraphs:
d. Any legally incorporated subsidiary
of yours in which you own more than
50% of the voting stock on the ef-
fective date of this endorsement.
However, "insured" does not include
any subsidiary that is an "insured"
under any other liability policy or
would be an "insured" under such a
policy but for its termination or the
exhaustion of its limit of insurance.
Coverage under this provision is af-
forded only for the first 180 days af-
ter you acquire or form the
organization or until the end of the
policy period, whichever comes first.
e. Any organization you newly acquire
or form, other than a partnership or
joint venture, and over which you
maintain ownership or a majority in-
terest. However, coverage under
this provision:
CA 70 78 10 13
Page 1 of 3
(1) Does not apply if the organiza-
tion you acquire or form is an
"insured" under another auto li-
ability policy or would be "in-
sured" under such a policy but
for its termination or the ex-
haustion of its limits of insur-
ance;
(2) Does not apply to "bodily injury"
or "property damage" that oc-
curred before you acquired or
formed the organization; and
(3) Is afforded only for the first 180
days after you acquire or form
the organization or until the end
of the policy period, whichever
comes first.
i. Any person or organization with
whom you agreed in writing in a
contract, agreement or permit, to
provide insurance such as is af-
forded under this policy.
This provision only applies if the
written contract or agreement has
been executed or permit has been
issued, prior to the "bodily injury" or
"property damage".
B. SUPPLEMENTAL PAYMENTS
SECTION II - COVERED AUTOS LIABILITY
GOVERAGE, item A. Cove�age, 2. Coverage
Extensions, a. Supplementary Payments, sub-
paragraphs {2) and (4) are deleted and re-
placed with the following:
(2) Up to $5,000 for cost of bail
bonds (including bonds for re-
lated traffic law violations) re-
quired because of an "accidenY'
we cover. We do not have to
furnish these bonds.
(4) All reasonable expenses in-
curred by the "insured" at our
request, including actual loss of
earnings up to $500 per day be-
cause of time off from work.
C. FELLOW EMPLOYEE EXCLUSION AMEND-
MENT �
SECTtON II - COVERED AUTOS LIABILITY
COVERAGE, item B. Exclusions, 5. Fellow
Employee does not apply if the "bodily injury"
results from the use of a covered "auto" you
own or hire.
D. COVERAGE EXTENSIONS
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item A. Coverage, 4. Coverage Exten-
sions, a. Transportation Expenses is replaced
with the following:
a, Transportation Expenses
We will pay up to $100 per day to a
maximum of $1,800 for transporta-
tion expense incurred by you be-
cause of the total 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
transportation expenses incurred
during the period beginning 48 hours
after the theft and ending, regardless
of the policy's expiration, when the
covered "auto" is returned to use or
we pay for its "loss".
The following is added to Item 4. Cover-
age Extensions:
c. Personal Effects
We will pay up to $500 for the "loss"
of your personal effects that are
contained in a covered "auto" due to
the total theft of the covered "auto."
We will pay only for those personal
effects that are contained in covered
"autos" for which you carry either
Comprehensive or Specified Causes
Of Loss Coverage.
Our payment for "loss" of or damage
to personal effects will apply only on
an excess basis over other collect-
ible insurance.
E. ADDITIONAL COVERAGES
SECTION III - PHYSICAL DAMAGE COVER-
AGE, A. Coverage, is amended to include the
following additional coverage items:
5. We will pay the expense of returning
stolen covered "auto" to you.
6. Fire Department Service Charge
When a fire department is called to save
or protect a covered "auto", its equip-
ment, its contents or occupants from a
Covered Cause Of Loss, we will pay up
to $1,000 for your liability for Fire De-
partment Service Charges:
(a) Assumed by contract or agreement
prior to loss; or
(b) Required by local ordinance.
No deductible applies to this additional
coverage.
F. AIRBAG COVERAGE - ACCIDENTAL DIS-
CHARGE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item B. Exclusions, subparagraph 3.a.
is deleted and replaced with the following:
CA 70 78 10 13
Page 2 of 3
a. Wear and tear, freezing, mechanical I.
or electrical breakdown. Mechanical
breakdown does not apply to the ac-
cidental discharge of an airbag.
G. GLASS REPAIR - WAIVER OF DEDUCTIBLE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, item D. Deductible the following para-
graph is added:
No deductible shall apply to glass dam-
age if the glass is repaired rather than
replaced.
H. KNOWLEDGE AND NOTICE OF AN ACCI-
DENT, CLAIM OR SUIT
SECTION IV - BUSINESS AUTO CONDITIONS,
Item A. Loss Conditions is amended as fol-
lows:
Subparagraph a. under Item 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss, is amended to include the following
paragraphs:
This requirement applies when the
"accident," claim, "suiY' or "loss" is
first known to:
(7) You, if you are an individual;
{2) A partner, if you are a partner-
ship; or
(3) An executive officer or insur-
ance manager, if you are a cor-
poration.
Subparagraph b.(2) under 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss is amended as follows:
(2) Immediately send us copies of
any request, demand, order,
notice, summons or legal paper
received concerning the claim
or "suit."
Your employees may know of
documents received concerning
a claim or "suiY'. This will not
mean that you have such know-
ledge, unless receipt of such
documents is known to you, any
of your executive officers or
partners or your insurance
manager.
UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 2.
Concealment, Misrepresentation Or Fraud is
amended to include the following additional
paragraph:
If you unintentionally fail to disclose any
hazards existing at the inception date of
your policy, we will not deny coverage
under this Coverage Part because of
such failure.
J. WORLDWIDE COVERAGE
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 7. Policy
Period, Coverage Territory, subparagraph (5�
is deleted and replaced with the following:
(5j Anywhere in the world, if:
(a) A covered "auto" of the private
passenger type is leased, hired,
rented or borrowed without a
driver for a period of 45 days or
less; and
(b) The "insured's" 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 Rico or Canada or in a
settlement we agree to.
(c) If, for such "autos" a"suiY' is
brought outside the territory de-
scribed in 7.(1) through 7.(4)
above, we will reimburse the
insured for defense expenses
incurred with our written con-
sent, but we will make no pay-
ment, nor will we reimburse the
insured for damages.
f�7�l:l�i[•I:�
Under SECTION V- DEFINITIONS, Item C. is
replaced by the following:
C. "Bodily injury" means bodily injury, sick-
ness or disease sustained by a person,
including mental anguish, mental injury
or death resulting from any of these.
"Bodily injury" includes mental anguish
or other mental injury resulting from
"bodily injury".
CA 70 78 10 13
Page 3 of 3
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
QDDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the Following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury",
"property damage" or "personal and adver-
tising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing oper-
ations for the additional insured(s) at the
location(s) designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following addi-
tional exclusions apply:
This insurance does not apply to "bodiiy in-
jury" or "property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the addi-
tional insured(s} at the location of the
covered operations has been completed;
or
2. That portion of "your work" out of which
the injury or damage arises has been put
to its intended use by any person or or-
ganization other than another contractor
or subcontractor engaged in performing
operations for a principal as a part of the
same project.
C. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services oftice, Inc., 20�2 CG 20 10 04 13
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) And Description Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury"
or "property damage" caused, in whole or in
part, by "your work" at the location desig-
nated and described in the schedule of this
endorsement performed for that additional
insured and included in the "products-
completed operations hazard".
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
1. Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is iess.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services Office, Inc , 2012 CG 20 37 04 13
P1NN/1COL
ASSURANCE
L & M Underground Inc
7529 S. Storm Mtn
Littleton, CO 80127
ENDORSEMENT: Blanket Waiver of Subrogation
NCCI #: WC000313B
Policy #: 4025271
7501 E. Lowry Blvd.
Denver, CO 80230-7006
303.361.4000 / 800.873.7242
Pinnacol.com
CRS, Commercial Risk Solutions, Inc
6600 E. Hampden Ave
Suite 200
Denver, CO 80224
(303) 996-7800
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
To any person or organization when agreed to under a written contract or agreement, as defined above
and with the insured, which is in effect and executed prior to any loss.
Effective Date:January 1, 2022 Expires on: January 1, 2023
Pinnacol Assurance has issued this endorsement December 17, 2021
7501 E. Lowry Blvd Denver, CO 80230-7006
Page 1 of 1 P ROSSIGNB - Underwriter 12/17/2021 15:52:38 4025271 59078392 359-B
DATE (MM/DDIYYYY)
ACOR� CERTIFICATE OF LIABILITY INSURANCE
�� 12/21/2021
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 policy(ies) must have ADDITIONAL INSURED provisions or 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 CONTACT
NAME: Daniel Glascock
Commercial Risk Solutions PHONE Fax
6600 E Hampden Ave Ste 200 a�c r,o eXc : 303-996-7801 aic No : 303-757-7719
Denver CO 80224 ADDR�ess: dglascock@crsdenver.com
INSURER(S) AFFORDING COVERAGE NAIC #
iNsuReRa: Westfield Insurance 24112
INSURED L&MUN-1 INSURER B: PIIlIlBCOI ASSUf81lC@ 41190
L & M Underground, Inc.
7529 S. Storm Mtn. iNsuReR c: Westchester Surplus Lines 10172
Littleton CO 80127 INSURER D:
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER:698343204 REVISION NUMBER:
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 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 BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICYNUMBER MM/DDIYYYY MM/DDIYYYY
A X COMMERCIALGENERALLIABILITY Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $1,OOQ000
DAMAGETO RENTED
CLAIMS-MADE %� OCCUR PREMISES Ea occurrence $ 500,000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $2,000,000
X POLICY � jE � � LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILELIABILITY Y CMM4932062 1/1/2022 1/1/2023 COMBINEDSINGLELIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
A X UMBRELLALIAB X OCCUR Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $10,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED X RETENTION $ $
g WORKERSCOMPENSATION Y 4025271 1/1/2022 1/1/2023 X PER OTH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $ 1,000,000
OFFICER/MEMBEREXCLUDED? N NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPER4TIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
C Pollution Liab G27494456 007 1/1/2022 1/1/2023 Limit 5,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: I-25 Electric Line Relocation Project City of Fort Collins and CDOT are included as additional insured for ongoing and completed operations on the General
Liability and included as additional insured on the Auto Liability with respect to operations of the named insured for the certificate holder as required by written
contract. Umbrella Liability follows form on the General Liability with respect to the additional insured. Workers Compensation coverage includes a waiver of
subrogation. General Liability policy has been endorsed to provide (30) days notice of cancellation except 10-day notice for non-payment of premium.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Division
215 North Mason Street, 2nd Floor
P O BOX rJSO AUTHORIZED REPRESENTATIVE
Fort Collins CO 80522 ����
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXPANDED ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
The coverage provided by this endorsement is summarized below and is intended to provide a general
coverage description only. For the details affecting each coverage, please refer to the terms and condi-
tions in this endorsement.
A. Who Is An Insured broadened:
• Additional Insured by Contract, Agreement or Permit
• Legaily Incorporated Subsidiaries
. Newly Acquired Organizations
B. Supplementary Payments
• Bail Bonds - $5000
• Loss of Earnings - $500
C. Fellow Employee Exclusion Amendment
D. Coverage Extensions
• Transportation Expenses
• Personal Effects (Excess Basis)
E. Additional Coverages
• Expenses paid for returning a stolen covered auto
• Fire Department Service Charge
F. Airbag Coverage - Accidental Discharge
G, Glass Repair - Waiver of Deductible
H. Knowledge and Notice of an Accident, Claim or Suit
I. Unintentional Failure To Disclose Hazards
J. Worldwide Coverage
K. Definitions
• Bodily lnjury Redefined
In addition to the policy amendments contained in A. through K. listed above, the endorsements listed
below will automatically be attached to your policy to complete the coverage provided by the Business
Auto Expanded Endorsement:
• Audio, Visual and Data Electronic Equipment Coverage Added Limits - CA 99 60
• Auto Loan/Lease Gap Coverage - CA 20 71
• Drive Other Car Coverage - Broadened Coverage For Named Individuals -(Executive
Officers/Spouses) - CA 99 10
• Employee Hired Autos - CA 20 54
• Employees As Insureds - CA 99 33
• Hired Auto Physical Damage (Refer to Auto Declarations page)
• Rental Reimbursement Coverage - CA 99 23
• Waiver of Transfer of Rights of Recovery (Waiver of Subrogation} - CA 04 44
A. WHO IS AN INSURED BROADENED
SECTION II - COVERED AUTOS LIABILITY
COVERAGE, item A. Coverage, 1, Who Is An
Insured is amended to include the following
additional paragraphs:
d. Any legally incorporated subsidiary
of yours in which you own more than
50% of the voting stock on the ef-
fective date of this endorsement.
However, "insured" does not include
any subsidiary that is an "insured"
under any other liability policy or
would be an "insured" under such a
policy but for its termination or the
exhaustion of its limit of insurance.
Coverage under this provision is af-
forded only for the first 180 days af-
ter you acquire or form the
organization or until the end of the
policy period, whichever comes first.
e. Any organization you newly acquire
or form, other than a partnership or
joint venture, and over which you
maintain ownership or a majority in-
terest. However, coverage under
this provision:
CA 70 78 10 13
Page 1 of 3
(1) Does not apply if the organiza-
tion you acquire or form is an
"insured" under another auto li-
ability policy or would be "in-
sured" under such a policy but
for its termination or the ex-
haustion of its limits of insur-
ance;
(2) Does not apply to "bodily injury"
or "property damage" that oc-
curred before you acquired or
formed the organization; and
(3) Is afforded only for the first 180
days after you acquire or form
the organization or until the end
of the policy period, whichever
comes first.
i. Any person or organization with
whom you agreed in writing in a
contract, agreement or permit, to
provide insurance such as is af-
forded under this policy.
This provision only applies if the
written contract or agreement has
been executed or permit has been
issued, prior to the "bodily injury" or
"property damage".
B. SUPPLEMENTAL PAYMENTS
SECTION II - COVERED AUTOS LIABILITY
GOVERAGE, item A. Cove�age, 2. Coverage
Extensions, a. Supplementary Payments, sub-
paragraphs {2) and (4) are deleted and re-
placed with the following:
(2) Up to $5,000 for cost of bail
bonds (including bonds for re-
lated traffic law violations) re-
quired because of an "accidenY'
we cover. We do not have to
furnish these bonds.
(4) All reasonable expenses in-
curred by the "insured" at our
request, including actual loss of
earnings up to $500 per day be-
cause of time off from work.
C. FELLOW EMPLOYEE EXCLUSION AMEND-
MENT �
SECTtON II - COVERED AUTOS LIABILITY
COVERAGE, item B. Exclusions, 5. Fellow
Employee does not apply if the "bodily injury"
results from the use of a covered "auto" you
own or hire.
D. COVERAGE EXTENSIONS
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item A. Coverage, 4. Coverage Exten-
sions, a. Transportation Expenses is replaced
with the following:
a, Transportation Expenses
We will pay up to $100 per day to a
maximum of $1,800 for transporta-
tion expense incurred by you be-
cause of the total 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
transportation expenses incurred
during the period beginning 48 hours
after the theft and ending, regardless
of the policy's expiration, when the
covered "auto" is returned to use or
we pay for its "loss".
The following is added to Item 4. Cover-
age Extensions:
c. Personal Effects
We will pay up to $500 for the "loss"
of your personal effects that are
contained in a covered "auto" due to
the total theft of the covered "auto."
We will pay only for those personal
effects that are contained in covered
"autos" for which you carry either
Comprehensive or Specified Causes
Of Loss Coverage.
Our payment for "loss" of or damage
to personal effects will apply only on
an excess basis over other collect-
ible insurance.
E. ADDITIONAL COVERAGES
SECTION III - PHYSICAL DAMAGE COVER-
AGE, A. Coverage, is amended to include the
following additional coverage items:
5. We will pay the expense of returning
stolen covered "auto" to you.
6. Fire Department Service Charge
When a fire department is called to save
or protect a covered "auto", its equip-
ment, its contents or occupants from a
Covered Cause Of Loss, we will pay up
to $1,000 for your liability for Fire De-
partment Service Charges:
(a) Assumed by contract or agreement
prior to loss; or
(b) Required by local ordinance.
No deductible applies to this additional
coverage.
F. AIRBAG COVERAGE - ACCIDENTAL DIS-
CHARGE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item B. Exclusions, subparagraph 3.a.
is deleted and replaced with the following:
CA 70 78 10 13
Page 2 of 3
a. Wear and tear, freezing, mechanical I.
or electrical breakdown. Mechanical
breakdown does not apply to the ac-
cidental discharge of an airbag.
G. GLASS REPAIR - WAIVER OF DEDUCTIBLE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, item D. Deductible the following para-
graph is added:
No deductible shall apply to glass dam-
age if the glass is repaired rather than
replaced.
H. KNOWLEDGE AND NOTICE OF AN ACCI-
DENT, CLAIM OR SUIT
SECTION IV - BUSINESS AUTO CONDITIONS,
Item A. Loss Conditions is amended as fol-
lows:
Subparagraph a. under Item 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss, is amended to include the following
paragraphs:
This requirement applies when the
"accident," claim, "suiY' or "loss" is
first known to:
(7) You, if you are an individual;
{2) A partner, if you are a partner-
ship; or
(3) An executive officer or insur-
ance manager, if you are a cor-
poration.
Subparagraph b.(2) under 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss is amended as follows:
(2) Immediately send us copies of
any request, demand, order,
notice, summons or legal paper
received concerning the claim
or "suit."
Your employees may know of
documents received concerning
a claim or "suiY'. This will not
mean that you have such know-
ledge, unless receipt of such
documents is known to you, any
of your executive officers or
partners or your insurance
manager.
UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 2.
Concealment, Misrepresentation Or Fraud is
amended to include the following additional
paragraph:
If you unintentionally fail to disclose any
hazards existing at the inception date of
your policy, we will not deny coverage
under this Coverage Part because of
such failure.
J. WORLDWIDE COVERAGE
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 7. Policy
Period, Coverage Territory, subparagraph (5�
is deleted and replaced with the following:
(5j Anywhere in the world, if:
(a) A covered "auto" of the private
passenger type is leased, hired,
rented or borrowed without a
driver for a period of 45 days or
less; and
(b) The "insured's" 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 Rico or Canada or in a
settlement we agree to.
(c) If, for such "autos" a"suiY' is
brought outside the territory de-
scribed in 7.(1) through 7.(4)
above, we will reimburse the
insured for defense expenses
incurred with our written con-
sent, but we will make no pay-
ment, nor will we reimburse the
insured for damages.
f�7�l:l�i[•I:�
Under SECTION V- DEFINITIONS, Item C. is
replaced by the following:
C. "Bodily injury" means bodily injury, sick-
ness or disease sustained by a person,
including mental anguish, mental injury
or death resulting from any of these.
"Bodily injury" includes mental anguish
or other mental injury resulting from
"bodily injury".
CA 70 78 10 13
Page 3 of 3
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
QDDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the Following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury",
"property damage" or "personal and adver-
tising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing oper-
ations for the additional insured(s) at the
location(s) designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following addi-
tional exclusions apply:
This insurance does not apply to "bodiiy in-
jury" or "property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the addi-
tional insured(s} at the location of the
covered operations has been completed;
or
2. That portion of "your work" out of which
the injury or damage arises has been put
to its intended use by any person or or-
ganization other than another contractor
or subcontractor engaged in performing
operations for a principal as a part of the
same project.
C. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services oftice, Inc., 20�2 CG 20 10 04 13
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) And Description Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury"
or "property damage" caused, in whole or in
part, by "your work" at the location desig-
nated and described in the schedule of this
endorsement performed for that additional
insured and included in the "products-
completed operations hazard".
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
1. Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is iess.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services Office, Inc , 2012 CG 20 37 04 13
P1NN/1COL
ASSURANCE
L & M Underground Inc
7529 S. Storm Mtn
Littleton, CO 80127
ENDORSEMENT: Blanket Waiver of Subrogation
NCCI #: WC000313B
Policy #: 4025271
7501 E. Lowry Blvd.
Denver, CO 80230-7006
303.361.4000 / 800.873.7242
Pinnacol.com
CRS, Commercial Risk Solutions, Inc
6600 E. Hampden Ave
Suite 200
Denver, CO 80224
(303) 996-7800
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
To any person or organization when agreed to under a written contract or agreement, as defined above
and with the insured, which is in effect and executed prior to any loss.
Effective Date:January 1, 2022 Expires on: January 1, 2023
Pinnacol Assurance has issued this endorsement December 17, 2021
7501 E. Lowry Blvd Denver, CO 80230-7006
Page 1 of 1 P ROSSIGNB - Underwriter 12/17/2021 15:52:38 4025271 59078392 359-B
DATE (MM/DDIYYYY)
ACOR� CERTIFICATE OF LIABILITY INSURANCE
�� 12/21/2021
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 policy(ies) must have ADDITIONAL INSURED provisions or 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 CONTACT
NAME: Daniel Glascock
Commercial Risk Solutions PHONE Fax
6600 E Hampden Ave Ste 200 a�c r,o eXc : 303-996-7801 aic No : 303-757-7719
Denver CO 80224 ADDR�ess: dglascock@crsdenver.com
INSURER(S) AFFORDING COVERAGE NAIC #
iNsuReRa: Westfield Insurance 24112
INSURED L&MUN-1 INSURER B: PIIlIlBCOI ASSUf81lC@ 41190
L & M Underground, Inc.
7529 S. Storm Mtn. iNsuReR c:
Littleton CO 80127 INSURER D:
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER:830308481 REVISION NUMBER:
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 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 BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICYNUMBER MM/DDIYYYY MM/DDIYYYY
A X COMMERCIALGENERALLIABILITY Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $1,OOQ000
DAMAGETO RENTED
CLAIMS-MADE %� OCCUR PREMISES Ea occurrence $ 500,000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $2,000,000
X POLICY � jE � � LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILELIABILITY Y CMM4932062 1/1/2022 1/1/2023 COMBINEDSINGLELIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
A X UMBRELLALIAB X OCCUR Y CMM4932062 1/1/2022 1/1/2023 EACHOCCURRENCE $10,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED X RETENTION $ $
g WORKERSCOMPENSATION Y 4025271 1/1/2022 1/1/2023 X PER OTH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $ 1,000,000
OFFICER/MEMBEREXCLUDED? N NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPER4TIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
A Leased/Rented Equip CMM4932062 1/1/2022 1/1/2023 Limit 250,000
Deductible 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: I-25 Electric Line Relocation Project City of Fort Collins and CDOT are included as additional insured for ongoing and completed operations on the General
Liability and included as additional insured on the Auto Liability with respect to operations of the named insured for the certificate holder as required by written
contract. Umbrella Liability follows form on the General Liability with respect to the additional insured. Workers Compensation coverage includes a waiver of
subrogation. General Liability policy has been endorsed to provide (30) days notice of cancellation except 10-day notice for non-payment of premium.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Division
215 North Mason Street, 2nd Floor
P O BOX rJSO AUTHORIZED REPRESENTATIVE
Fort Collins CO 80522 ����
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXPANDED ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
The coverage provided by this endorsement is summarized below and is intended to provide a general
coverage description only. For the details affecting each coverage, please refer to the terms and condi-
tions in this endorsement.
A. Who Is An Insured broadened:
• Additional Insured by Contract, Agreement or Permit
• Legaily Incorporated Subsidiaries
. Newly Acquired Organizations
B. Supplementary Payments
• Bail Bonds - $5000
• Loss of Earnings - $500
C. Fellow Employee Exclusion Amendment
D. Coverage Extensions
• Transportation Expenses
• Personal Effects (Excess Basis)
E. Additional Coverages
• Expenses paid for returning a stolen covered auto
• Fire Department Service Charge
F. Airbag Coverage - Accidental Discharge
G, Glass Repair - Waiver of Deductible
H. Knowledge and Notice of an Accident, Claim or Suit
I. Unintentional Failure To Disclose Hazards
J. Worldwide Coverage
K. Definitions
• Bodily lnjury Redefined
In addition to the policy amendments contained in A. through K. listed above, the endorsements listed
below will automatically be attached to your policy to complete the coverage provided by the Business
Auto Expanded Endorsement:
• Audio, Visual and Data Electronic Equipment Coverage Added Limits - CA 99 60
• Auto Loan/Lease Gap Coverage - CA 20 71
• Drive Other Car Coverage - Broadened Coverage For Named Individuals -(Executive
Officers/Spouses) - CA 99 10
• Employee Hired Autos - CA 20 54
• Employees As Insureds - CA 99 33
• Hired Auto Physical Damage (Refer to Auto Declarations page)
• Rental Reimbursement Coverage - CA 99 23
• Waiver of Transfer of Rights of Recovery (Waiver of Subrogation} - CA 04 44
A. WHO IS AN INSURED BROADENED
SECTION II - COVERED AUTOS LIABILITY
COVERAGE, item A. Coverage, 1, Who Is An
Insured is amended to include the following
additional paragraphs:
d. Any legally incorporated subsidiary
of yours in which you own more than
50% of the voting stock on the ef-
fective date of this endorsement.
However, "insured" does not include
any subsidiary that is an "insured"
under any other liability policy or
would be an "insured" under such a
policy but for its termination or the
exhaustion of its limit of insurance.
Coverage under this provision is af-
forded only for the first 180 days af-
ter you acquire or form the
organization or until the end of the
policy period, whichever comes first.
e. Any organization you newly acquire
or form, other than a partnership or
joint venture, and over which you
maintain ownership or a majority in-
terest. However, coverage under
this provision:
CA 70 78 10 13
Page 1 of 3
(1) Does not apply if the organiza-
tion you acquire or form is an
"insured" under another auto li-
ability policy or would be "in-
sured" under such a policy but
for its termination or the ex-
haustion of its limits of insur-
ance;
(2) Does not apply to "bodily injury"
or "property damage" that oc-
curred before you acquired or
formed the organization; and
(3) Is afforded only for the first 180
days after you acquire or form
the organization or until the end
of the policy period, whichever
comes first.
i. Any person or organization with
whom you agreed in writing in a
contract, agreement or permit, to
provide insurance such as is af-
forded under this policy.
This provision only applies if the
written contract or agreement has
been executed or permit has been
issued, prior to the "bodily injury" or
"property damage".
B. SUPPLEMENTAL PAYMENTS
SECTION II - COVERED AUTOS LIABILITY
GOVERAGE, item A. Cove�age, 2. Coverage
Extensions, a. Supplementary Payments, sub-
paragraphs {2) and (4) are deleted and re-
placed with the following:
(2) Up to $5,000 for cost of bail
bonds (including bonds for re-
lated traffic law violations) re-
quired because of an "accidenY'
we cover. We do not have to
furnish these bonds.
(4) All reasonable expenses in-
curred by the "insured" at our
request, including actual loss of
earnings up to $500 per day be-
cause of time off from work.
C. FELLOW EMPLOYEE EXCLUSION AMEND-
MENT �
SECTtON II - COVERED AUTOS LIABILITY
COVERAGE, item B. Exclusions, 5. Fellow
Employee does not apply if the "bodily injury"
results from the use of a covered "auto" you
own or hire.
D. COVERAGE EXTENSIONS
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item A. Coverage, 4. Coverage Exten-
sions, a. Transportation Expenses is replaced
with the following:
a, Transportation Expenses
We will pay up to $100 per day to a
maximum of $1,800 for transporta-
tion expense incurred by you be-
cause of the total 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
transportation expenses incurred
during the period beginning 48 hours
after the theft and ending, regardless
of the policy's expiration, when the
covered "auto" is returned to use or
we pay for its "loss".
The following is added to Item 4. Cover-
age Extensions:
c. Personal Effects
We will pay up to $500 for the "loss"
of your personal effects that are
contained in a covered "auto" due to
the total theft of the covered "auto."
We will pay only for those personal
effects that are contained in covered
"autos" for which you carry either
Comprehensive or Specified Causes
Of Loss Coverage.
Our payment for "loss" of or damage
to personal effects will apply only on
an excess basis over other collect-
ible insurance.
E. ADDITIONAL COVERAGES
SECTION III - PHYSICAL DAMAGE COVER-
AGE, A. Coverage, is amended to include the
following additional coverage items:
5. We will pay the expense of returning
stolen covered "auto" to you.
6. Fire Department Service Charge
When a fire department is called to save
or protect a covered "auto", its equip-
ment, its contents or occupants from a
Covered Cause Of Loss, we will pay up
to $1,000 for your liability for Fire De-
partment Service Charges:
(a) Assumed by contract or agreement
prior to loss; or
(b) Required by local ordinance.
No deductible applies to this additional
coverage.
F. AIRBAG COVERAGE - ACCIDENTAL DIS-
CHARGE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, Item B. Exclusions, subparagraph 3.a.
is deleted and replaced with the following:
CA 70 78 10 13
Page 2 of 3
a. Wear and tear, freezing, mechanical I.
or electrical breakdown. Mechanical
breakdown does not apply to the ac-
cidental discharge of an airbag.
G. GLASS REPAIR - WAIVER OF DEDUCTIBLE
SECTION III - PHYSICAL DAMAGE COVER-
AGE, item D. Deductible the following para-
graph is added:
No deductible shall apply to glass dam-
age if the glass is repaired rather than
replaced.
H. KNOWLEDGE AND NOTICE OF AN ACCI-
DENT, CLAIM OR SUIT
SECTION IV - BUSINESS AUTO CONDITIONS,
Item A. Loss Conditions is amended as fol-
lows:
Subparagraph a. under Item 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss, is amended to include the following
paragraphs:
This requirement applies when the
"accident," claim, "suiY' or "loss" is
first known to:
(7) You, if you are an individual;
{2) A partner, if you are a partner-
ship; or
(3) An executive officer or insur-
ance manager, if you are a cor-
poration.
Subparagraph b.(2) under 2. Duties In
The Event Of Accident, Claim, Suit Or
Loss is amended as follows:
(2) Immediately send us copies of
any request, demand, order,
notice, summons or legal paper
received concerning the claim
or "suit."
Your employees may know of
documents received concerning
a claim or "suiY'. This will not
mean that you have such know-
ledge, unless receipt of such
documents is known to you, any
of your executive officers or
partners or your insurance
manager.
UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 2.
Concealment, Misrepresentation Or Fraud is
amended to include the following additional
paragraph:
If you unintentionally fail to disclose any
hazards existing at the inception date of
your policy, we will not deny coverage
under this Coverage Part because of
such failure.
J. WORLDWIDE COVERAGE
Under SECTION IV - BUSINESS AUTO CON-
DITIONS, B. General Conditions, 7. Policy
Period, Coverage Territory, subparagraph (5�
is deleted and replaced with the following:
(5j Anywhere in the world, if:
(a) A covered "auto" of the private
passenger type is leased, hired,
rented or borrowed without a
driver for a period of 45 days or
less; and
(b) The "insured's" 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 Rico or Canada or in a
settlement we agree to.
(c) If, for such "autos" a"suiY' is
brought outside the territory de-
scribed in 7.(1) through 7.(4)
above, we will reimburse the
insured for defense expenses
incurred with our written con-
sent, but we will make no pay-
ment, nor will we reimburse the
insured for damages.
f�7�l:l�i[•I:�
Under SECTION V- DEFINITIONS, Item C. is
replaced by the following:
C. "Bodily injury" means bodily injury, sick-
ness or disease sustained by a person,
including mental anguish, mental injury
or death resulting from any of these.
"Bodily injury" includes mental anguish
or other mental injury resulting from
"bodily injury".
CA 70 78 10 13
Page 3 of 3
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
QDDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the Following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury",
"property damage" or "personal and adver-
tising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing oper-
ations for the additional insured(s) at the
location(s) designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following addi-
tional exclusions apply:
This insurance does not apply to "bodiiy in-
jury" or "property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the addi-
tional insured(s} at the location of the
covered operations has been completed;
or
2. That portion of "your work" out of which
the injury or damage arises has been put
to its intended use by any person or or-
ganization other than another contractor
or subcontractor engaged in performing
operations for a principal as a part of the
same project.
C. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services oftice, Inc., 20�2 CG 20 10 04 13
POLICY NUMBER: CMM 4932062 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) And Description Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s)
or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury"
or "property damage" caused, in whole or in
part, by "your work" at the location desig-
nated and described in the schedule of this
endorsement performed for that additional
insured and included in the "products-
completed operations hazard".
However:
1. The insurance afforded to such additional
insured only applies to the extent per-
mitted by law; and
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such
additional insured will not be broader
than that which you are required by the
contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to
these additional insureds, the following is
added to Section III - Limits Of Insurance:
If coverage provided to the additional insured
is required by a contract or agreement, the
most we will pay on behalf of the additional
insured is the amount of insurance:
1. Required by the contract or agreement;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is iess.
This endorsement shall not increase the ap-
plicable Limits of Insurance shown in the
Declarations.
O Insurance Services Office, Inc , 2012 CG 20 37 04 13
P1NN/1COL
ASSURANCE
L & M Underground Inc
7529 S. Storm Mtn
Littleton, CO 80127
ENDORSEMENT: Blanket Waiver of Subrogation
NCCI #: WC000313B
Policy #: 4025271
7501 E. Lowry Blvd.
Denver, CO 80230-7006
303.361.4000 / 800.873.7242
Pinnacol.com
CRS, Commercial Risk Solutions, Inc
6600 E. Hampden Ave
Suite 200
Denver, CO 80224
(303) 996-7800
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
To any person or organization when agreed to under a written contract or agreement, as defined above
and with the insured, which is in effect and executed prior to any loss.
Effective Date:January 1, 2022 Expires on: January 1, 2023
Pinnacol Assurance has issued this endorsement December 17, 2021
7501 E. Lowry Blvd Denver, CO 80230-7006
Page 1 of 1 P ROSSIGNB - Underwriter 12/17/2021 15:52:38 4025271 59078392 359-B