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HomeMy WebLinkAboutKing Surveyors - Insurance CertificateSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 06/02/2025 Marsh McLennan Agency, LLC - Bouchard Region 101 North Starcrest Drive Clearwater, FL 33765 (727) 447-6481 American Zurich Insurance Company 40142 FrankCrum 1, Inc. Alt. Emp: King Surveyors LLC 100 South Missouri Avenue Clearwater, FL 33756 Coverage is provided for only those co-employees of, but not subcontractors to: WC 47-58-512-14 06/01/2025 06/01/2025 06/01/2026 06/01/2026 1,000,000 1,000,000 1,000,000 25FL080977203 12053-CO Re: AECOM Project No.: 04194532607; Client Reference No. 8976 PSA WO Agreement 12-10-19. Project Name: Halligan Project. Location Description: Halligan Reservoir is located about 25 miles northwest of Fort Collins on the North Fork of the Cache la Poudre River is Sections 33 and 34, Township 11 North, Range 71 West of the Sixth P.M. Larimer County, Colorado. Halligan Reservoir is approximately 14 miles northwest of Seaman Reservoir X Endorsements: Waiver of Subrogation, 30 days written cancel notice (10 days for non payment of premium) King Surveyors LLC 650 E Garden Dr Windsor, CO 80550 The City of Fort Collins, Colorado Attn: Ms. Pat Johnson/Senior Buyer 215 N. Mason St. 2nd Floor Fort Collins, CO 80522 Client# A Location Coverage Period: X WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 IN FAVOR OF: WORK PERFORMED BY CO-EMPLOYEES OF: ON THE FOLLOWING PROJECT: FEE FOR THIS WAIVER IS: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No: Endorsement No: Insured: Premium: $ Insurance Company: Countersigned By: Authorized Representative Au Authorized Representative WC 124 (4-84) WC 00 03 13 Copyright 1983 National Council on Compensation Insurance. Page 1 The City of Fort Collins, Colorado Attn: Ms. Pat Johnson/Senior Buyer 215 N. Mason St. 2nd Floor Fort Collins, CO 80522 King Surveyors LLC 650 E Garden Dr Windsor, CO 80550 Re: AECOM Project No.: 04194532607; Client Reference No. 8976 PSA WO Agreement 12-10-19. Project Name: Halligan Project. Location Description: Halligan Reservoir is located about 25 miles northwest of Fort Collins on the North Fork of the Cache la Poudre River is Sections 33 and 34, Township 11 North, Range 71 West of the Sixth P.M. Larimer County, Colorado. Halligan Reservoir is approximately 14 miles northwest of Seaman Reservoir 06/01/2025 WC 47-58-512-14 FrankCrum 1, Inc. Alt. Emp: King Surveyors LLC American Zurich Insurance Company Premium will be waived