HomeMy WebLinkAboutLevi Contractors, Inc. - INSURANCE CERTIFICATE ACC) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
06/29/2023
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 Christine Walker,CISR,CRIS
NAME:
Moody Insurance Agency, Inc. PHONE (303)824-6600 FAX (303)370-0118
A/C No Ext: A/C,No
8055 East Tufts Avenue E-MAIL christine.walker@moodyins.com
ADDRESS:
Suite 1000 INSURER(S)AFFORDING COVERAGE NAIC k
Denver CO 80237 INSURER A: BITCO General Insurance Corporation 20095
INSURED INSURER B: Pinnacol Assurance 41190
Levi Contractors,Inc. INSURER C:
10981 Brighton Rd INSURER D:
INSURER E:
Henderson CO 80640 INSURER F:
COVERAGES CERTIFICATE NUMBER: 23.24 Master 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 ADDLSUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YY-Y LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADEX OCCUR DAMA E T REN 100,000
PREMISES Ea occurrenceI $
MED EXP(Any one person) s 5,000
A Y CLP3731841 07/01/2023 07/01/2024 PERSONAL BADVINJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
JECT ❑ LOC PRODUCTS-COMP/OPAGG $POLICY PRO 2,000,000
OTHER: Pollution Liability- $ 1,000,000
AUTOMOBILE LIABILITY COMME-D SINGLE LIMIT $ 1,000,000
Ea accident
X ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED CAP3731842 07/01/2023 07/01/2024 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
q I Uninsured motorist BI- $ 1,000,000
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000
A Excess LIAR CLAIMS-MADE CUP2822388 07/01/2023 07/01/2024 AGGREGATE $ 4,000,000
DIED X RETENTION$ 10,000 $
WORKERS COMPENSATION S PER OTH-
AND EMPLOYERS'LIABILITY TATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 1,000,000
B OFFICER/MEMBER EXCLUDED? N/A 1964210 07/01/2023 07/01/2024 E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
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 Attn:Engineering Department ACCORDANCE WITH THE POLICY PROVISIONS.
281 North College Avenue
AUTHORIZED REPRESENTATIVE
Fort Collins CO 80524 110Qlaq
@ 1988988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 00012468
LOC#:
ACCA?"
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY
NAMEDINSURED
Moody Insurance Agency,Inc. Levi Contractors,Inc.
POLICY NUMBER
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes
CONTRACTUAL LIABILITY APPLIES PER POLICY TERMS AND CONDITIONS
Limited Jobsite Pollution-BITCO General Insurance Corporation,Policy Number CLP3731841,Effective Date:07/01/2023-07/01/2024,Limit:
$1,000,000/Deductible:$1,000
Leased/Rented Equipment-BITCO General Insurance Corporation,Policy Number CLP3731841,Effective Date:07/01/2022-07/01/2023,Limit:
$50,000/Deductible:$1,000
Builders Risk-BITCO General Insurance Corporation,Policy Number CLP3731841,Effective Date:07/01/2023-07/01/2024,Limit:$500,000/Deductible:
$1,000
General Liability:
GL-3085(09/11)Form Attached Includes:
Blanket Additional Insured status applies only to the extent provided in form GL-3085(09/11)when required by written contract.
Blanket Waiver of Subrogation applies only to the extent provided in form GL-3085(09/11)when required by written contract.
Primary and Non-Contributory status only to the extent provided in form GL-3085(09/11)when required by written contract.
Designated Project General Aggregate applies only to the extent provided in form GL-3085(09/11)when required by written contract.
60 Day Notice of Cancellation for any other reason.
GOX-2287-CN(01/93)Form Attached Includes:
30 Day Notice of Cancellation for non-payment of premium.
Auto Liability:
AP-0401 (10/17)Form Attached Includes:
Blanket Additional Insured status applies only to the extent provided in form AP-0401 (10/17)when required by written contract.
Blanket Waiver of Subrogation applies only to the extent provided in form AP-0401 (10/17)when required by written contract.
Primary and Non-Contributory status only to the extent provided in form AP-0401 (10/17)when required by written contract.
Excess Liability:
Excess Liability policy is on a follow form basis for the following underlying insurance coverages:General Liability,Automobile Liability,and Employers
Liability. Additional insured status will follow when required by written contract including Primary and Non-Contributory status when required by written
contract.
Worker's Compensation:
359-B From Attached Includes Blanket Waiver of Subrogation.Status applies when required by written contract.
IMPORTANT:
The policy forms referenced will be sent via email only.To obtain copies,please send your request with the email address to certrequest@moodyins.com
ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD