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HomeMy WebLinkAboutDON KEHN CONSTRUCTION - INSURANCE CERTIFICATE (3)Client# 52210 8DONKEHN ACORD,M CERTIFICATE OF LIABILITY INSURANCE "" 09/22107 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 South Colorado Boulevard HOLDER THIS CERTIFICATE DOES NOT AMEND, ALTER THE COVERAGE AFFORDED BY THE POLICIES EXTEND OR BELOW Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIL # INSURED INSURER A Travelers Indemnity Company 25658 Don Kehn Construction, Inc INSURER B Travelers Property Casualty Company 36161 6550 SCR5 INSURERC Pinnacol Assurance 10780 Fort Collins, CO 80528 INSURER D INSURER E COVERAGES 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 AFFCRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS NSR LTR ADD L NSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIY POLICY EXPIRATION DATE MMIDDIYV LIMITS A GENERAL LIABILITY C0161E8893 11/01/06 11/01/07 EACH OCCURRENCE I $1000.000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE 51 OCCUR DAMAGETO RENTED PR MI E $300 OOO MED EXP (Any ane person) $5 000 PERSONAL 8 ADV INJURY $1 00O 000 AI# CG D2 46 (08105) GENERAL AGGREGATE I $2 000 000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP GG s2,000,000 POLICY 7 ECT X LOC B AUTOMOBILE LIABILITY ANY AUTO 810161E8893 11/01/06 11/01/07 COMBINED SINGLE LIMI71 (Ea accident)$1,000,000 X BODILY INJURY (Per Person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIRED AUTOS NON OVNJED AUTOS X X PROPERTY DAMAGE (Per accident) S Ltd Pollution GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ OTHER THAN EA C 5 ANY AUTO G S AUTO ONLY A B EXCESSIUMBRELLA LIABILITY CUP161E8893 11/01/06 11/01/07 EACH OCCURRENCE $2000000 X OCCUR 7 CLAIMS MADE AGGREGATE s2,000,000 $ I S DEDUCTIBLE $ X RETENTION S10,000 C WORKERS COMPENSATION AND 2093950 10/01/07 10/01/08 X dWCSTAru -- O ITO YUMJTS H R E L EACH ACCIDENT $500 0OO EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDEDo E L DISEASE EA EMPLOYEE S500,000 If yes describe under SPECIAL PROVISIONS below E L DISEASE POLICY U"I T $500 O00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description 6045 Asphalt Supply The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLE BEFORE THE EXPIRATION City of Fort Collins DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN Administrative Services NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL Purchasing Division IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INS RER ITS AGENTS OR PO Box 580 REPRESENTATIVES AUTHORIZED REPRESENTATIVE r d % Fort Collins, CO 80522-0580 ACORD 25 (2001108) 1 of 3 #S5519761M551963 Y 8MSTY © ACORDI CORPORATION 198 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed A st on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies require an endorsement A statement on this certificate does not confer rights to the certif holder in lieu of such endorsement(s) DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract betw er the issuing insurer(s), authorized representative or producer, and the certificate holder, nor doe it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed ther�on ACORD 25-S (2001108) 2 of 3 #S551976/M551963 DESCRIPTIONS'(Continued froin'Page 1) work performed by the Insured for the Additional Insureds All coverage terms, conditions and exclusions of the policy apply Additional Insureds City of Fort Collins The Additional Insured endorsement which is referenced above under "Type of Insurance -General Liability" is attached This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract The following cancellation conditions always apply -10 days for non-payment of premium - If policy shown, 10 days for Workers' Compensation for fraud, material misrepresentation, non-payment of premium, other reasons approved by the Commissioner of Insurance AMS 25 3 (2001/08) 3 of 3 #S551976/M551963 COMMERCIAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section ll) is amended to include any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Cover- age Part, but: a) Only with respect to liability for "bodily injury", "properly damage" or "personal injury", and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. 2. The insurance provided to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability re- quired by that "written contract requiring in- surance". This endorsement shall not in- crease the limits of insurance described in Section III — Limits Of Insurance. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage" or "personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: i. The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications: and ii. Supervisory, inspection, architectural or engineering activities. c) The insurance provided to th sured does not apply to "b "property damage" caused I and included in the "products erations hazard" unless the " requiring insurance" specifica to provide such coverage for insured, and then the insurar the additional insured applie "bodily injury" or "property dz curs before the end of the pe which the "written contract ante" requires you to provid or the end of the policy perm earlier. 3. The insurance provided to the a by this endorsement is excess ov collectible "other insurance", w excess, contingent or on any of available to the additional insure cover under this endorsement. "written contract requiring insura requires that this insurance appl basis or a primary and non -cot this insurance is primary to "o available to the additional insur that person or organization as a for such loss, and we will not "other insurance". But the insura the additional insured by this end excess over any valid and coII4 surance", whether primary, exce on any other basis, that is avail tional insured when that person an additional insured under sof ante". I 4 ULLY e additional in- odily injury" or )y "your work" -completed op - written contract Ily requires you that additional ice provided to s only to such mage" that oc- nod of time for requiring insur- such coverage d, whichever is ditional insured �r any valid and tether primary, �r basis, that is i for a loss we iowever, if the ce" specifically on a primary tributory basis, her insurance" i which covers named insured ;hare with that ice provided to )rsement still is Jible "other in- s, contingent or nle to the addi- organization is h "other insur- As a condition of coverage provided to the additional insured by this endorse ment: a) The additional insured must give us written notice as soon as practicab e of an "occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: J CG D2 46 08 05 © 2005 The St. Paul Travelers Companies, Inc. 015972 Page 1 of 2 COMMERCIAL GENERAL LIABILITY i. How, when and where the "occurrence" or offense took place, ii. The names and addresses of any injured persons and witnesses, and iii. The nature and location of any injury or damage arising out of the 'occurrence" or offense. b) If a claim is made or "suit' is brought against the additional insured, the additional insured must: i. Immediately record the specifics of the claim or "suit' and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit' as soon as practicable. c) The additional insured must immediately send us copies of all legal papers received in connection with the claim or "suit', cooperate with us in the investigation or settlement of the claim or defense against the "suit', and otherwise comply with all policy conditions. d) The additional insured must tender the de- fense and indemnity of any claim or "suit' to any provider of "other insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement is primary to 'other insur- ance" available to the additional insured which covers that person or organization as a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. — DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you, b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 © 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05