HomeMy WebLinkAboutEMPIRE CARPENTRY - INSURANCE CERTIFICATE (3)05/09/2007 13:57 970-229-9087 Came J Peterson Page 1/1
CERTIFICATE OF LIABILITY INSURANCE �1114,5
American Family Insurance Company ❑
American Family Mutual Insurance Company if selection box is not checked.
6000 American Pky Madison, Wisconsin 53783-0001
Agent's Name, Address and Phone Number (Agt./Dist.) Insured's Name and Address:
Larry D Peterson (0041316) Empire Carpentry LLC
149 W Harvard, Suite102 PO Box 245
Fort Collins„ CO 80525 Bellvue, CO 80512-0245
970-229-9393
This certificate Is Issued as a matter of Information only and confers no rights upon the Certificate Holder.
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-. COVERAGES
This is to certify that 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.
POLICY TYPE
TYPE OF INSURANCE POLICY NUMBER Effective Expiration LIMITS OF LIABILITY
MO,De ,Yr) MO,Da ,Yr
Homeowners/ Bodily Injury and Property Damage
Mobilehomeowners Liability Each Occurrence
Boatowners Liability Bodily Injury and Property Damage
Each Occurrence
Personal Umbrella Liability Bodily Injury and Property Damage
Each Occurrence
Farm/Ranch Liability Farm & Personal Liability Each Occurrence
Farm Employees Liability Each Occurrence
Statutory •
Workers Compensation and Each Accident
Employers Liability + Disease - Each Employee
Disease -Polic Limit
General Liability General Aggregate $ 2,000,000
® Commercial General 05-X16943-14 10/30/2006 10/302007 Products - Completed Operations Aggregate $ 2,000,000
Liability (occurrence) Personal and Advertising Injury $ 1,000,000
❑ Each Occurrence $ 1,000,000
❑ Fire Damage (Any One Fire) $ 100,000
Medical Expense (Any One Person) $ 5,000
Buslnessowners Liability Each Occurrence + +
Aggregate + +
Automobile Liability Bodily Injury- Each Person $1,000,000
® Owned Autos (Basic form) 05-X90782-02 09/012006 09/012007 Bodily Injury- Each Accident $1,000,000
❑ Owned Autos (Comp form) Property Damage $1,000,000
❑ Hired Autos Bodily Injury & Property Damage Combined
❑ Non -owned Autos
❑ Garage liability
Excess Liability
❑ Commercial Blanket Excess Each Occurrence/Aggregate
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS +The individual or partners shown as Insured "' elected to be covered
The City of Fort Collins Department of Purchasing is listed as an additional Insured on the as employees under this policy.
CG 2010 07 04 endorsement.. ++ Products -Completed Operations aggregate is equal to each
occurrence limit and is included in policy aggregate.
CERTIFICATE HOLDER'S NAME AND
CERTIFICATE HOLDER'S NAME AND
ADDRESS
CANCELLATION
ADDITIONAL INSURED
® Should any of the above described policies be canceled before the
City of Fort Collins
expiration date thereof, the company will endeavor to mail'( 10 days) written
Dept of Purchasing
notice to the Certificate Holder named, but failure to mail such notice shall
PO Box 580
impose no obligation or liability of any kind upon the company, its agents or
Fort Collins, CO 80522
representatives. *10 days unless different number of days shown.
Fax:221-6707
❑This certifies coverage on the date of issue only. The above described
Attn: John Stevens
policies are subject to cancellation in conformity with their terms and by the
laws of the state of issue.
DATE ISSUED
AUTHORIZED REPRESENTATIVE
5/09/2007
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U-201 Ed. 1196 ORIGINAL - Certificate Holder, COPIES to Services, Insured, Agent JtOCK NO. Ubbbt$