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HomeMy WebLinkAboutEmpire Drilling LLC - Insurance Certificate 2025-2026 ACCW"® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/30/2024 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 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 Katie Klimek Ewing-Leavitt Insurance Agency, Inc. PHC No Ea (970)679-7333 AX No: (866)456-4265 JAI5689 McWhinney Blvd. E-MAIL ADDRESS: katie-klimek@leavitt.com INSURERS AFFORDING COVERAGE NAIC# Loveland CO 80538 INSURERA:Acuity, A Mutual Insurance Company 14184 INSURED INSURER B:Pinnacol Assurance 41190 Empire Drilling LLC INSURERC: 6715 W 32nd Street INSURERD: INSURER E: Greeley 80634 INSURERF: COVERAGES CERTIFICATE NUMBER:25/26 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 CONTRACTOR 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 ADDL SUBR EFF LTR TYPE OF INSURANCEINSD POLICY NUMBER MM DDY/YYYY MMIDDY/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 250,000 A CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ X Blkt Additional Insured X ZT7515 1/2/2025 1/2/2026 MED EXP(Any one person) $ 10,000 X Blkt Waiver of Subrogation PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATELIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY a ECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY Oa BINEDtSINGLE LIMIT E a $ 1,000,000 A X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS ZT7515 1/2/2025 1/2/2026 BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ X Blkt Addtl lnsd X Blkt Waiv of Subg $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ ZT7515 1/2/2025 1/2/2026 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X I STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N I A B (Mandatory In NH) 4248656 1/1/2025 1/1/2026 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Fort Collins is named as additional insured as respects General Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 281 N College Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80524 AUTHORIZED REPRESENTATIVE Katie Klimek/KAKLIM ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)