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HomeMy WebLinkAboutDON KEHN - INSURANCE CERTIFICATEannNil(FHNI ACORDT� CERTIFICATE OF LIABILITY INSURANCE 09;zz/o,°"Y"Y' PRODUCER HRH of Colorado 720 South Colorado Boulevard Suite 60ON Denver, CO 80246 THIS CERTIFICATE IS ISSUED AS A MATTER OF ONLY AND CONFERS NO RIGHTS UPON THE CE HOLDER THIS CERTIFICATE DOES NOT AMEND ALTER THE COVERAGE AFFORDED BY THE PO INFORMATION TIFICATE EXTEND OR ICIES BELOW INSURERS AFFORDING COVERAGE NAIC # INSURED Don Kehn Construction, Inc 6550 SCR5 Fort Collins, CO 80528 INSURER A Travelers Indemnity Company 25658 INSURER Travelers Property Casualty Compar y 36161 INSURERC Pmnacol Assurance 10780 INSURER D INSURER E rnvconr_cc THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED N TWI THSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BEIIISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR NOD L TYPE OF INSURANCE NSR POLICY NUMBER POLICY EFFECTIVE DATE MMIDD/YY POLICY EXPIRATION DATE MMIDDIVV LIMITS A GENERAL LIABILITY C0161E8893 11/01/06 11/01/07 EACH OCCURRENCE $1000000 PREMISESEaoccurr°encel $300000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one Person)I $5 000 CLAIMS MADE � OCCUR PERSONAL & ADV INJURY, $1 000 000 AI# CG D2 46 (08/05) GENERALAGGREGATE $2 000 000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $2 000 000 POLICY PRO X LOc B AUTOMOBILE LIABILITY ANY AUTO 810161E8893 11/01/06 11/01/07 COMBINED SINGLE LIMIT (Eaacadenl) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIRED AUTOS NON OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTOONLY EAACCIDE T $ OTHER THAN EA C $ ANY AUTO 5 AUTO ONLY ADO B EXCESSIUMBRELLALIABILITY CUP161EB893 11/01/06 11/01/07 EACH OCCURRENCE $2000000 X1 OCCUR F-ICLAIMS MADE AGGREGATE s2,000,000 $ DEDUCTIBLE $ X RETENTION $ 10 000 C WORKERS COMPENSATION AND 2093950 10/01/07 10/01/08 X WCSTANTU OTH ITS I I ER EMPLOYERS LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? �✓ EL EACH ACCIDENT I $500,000 EL DISEASE EAEMPLO1YEE $500,000 If yes SPECIALibe under PROVISIONSbel ECIAL Pow EL DISEASE POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description Furnishing Asphalt The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects (See Attached Descriptions) City of Ft Collins ATTN Director of Purchasing & Risk Management P O Box 580 Ft Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELL D BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAI zn- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED Tr THE LEFT BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THEI SURER ITSAGENTSOR REPRESENTATIVE ACI 25 (zsuvnsl 1 of 3 #S551978IM551963 BMSTY U Hn.0 i U GUKYUKNl1VIN IUeU IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed A sty 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 between the issuing inswer(s), authorized representative or producer, and the certificate holder, nor does) it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereion ACORD 25S (2001/08) 2 of 3 #S551978/M551963 DESCRIPTIONS,{Continlued from 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 (2001109) 3 of 3 #S551975/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 II) 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", "property 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 r 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 n Supervisory, inspection, architectural or engineering activities c) The insurance provided to tt sured does not apply to "ti "property damage" caused and included in the "product! erations hazard" unless the 'I requiring insurance" specihca to provide such coverage toi insured, and then the insurai the additional insured appliE "bodily injury" or "property d; curs before the end of the p( which the "written contract ante" requires you to providE or the end of the policy pert( earlier ULLY e additional in- odily injury" or cy "your work" completed op - written contract Ily requires you that additional ice provided to s only to such image" that oc- mod of time for requiring insur- such coverage id. whichever is 3 The insurance provided to the a by this endorsement is excess ov collectible "other insurance", wr excess, contingent or on any oth available to the additional insure cover under this endorsement "written contract requiring insura� requires that this insurance appl, basis or a primary and non -con this insurance is primary to "o available to the additional insure that person or organization as a for such loss, and we will not "other insurance" But the insurar the additional insured by this ends excess over any valid and collet surance", whether primary, exces on any other basis, that is availa tional insured when that person of an additional insured under suc ante" 4 As a condition of coverage p additional insured by this endorser a) The additional insured must notice as soon as practicable rence" or an offense which claim To the extent possib should include litional insured any valid and ether primary, r basis, that is for a loss we owever, if the :e" specifically on a primary ributory basis, ier insurance" which covers iamed insured hare with that ce provided to rsement still is tible "other in- , contingent or ale to the addr organization is i "other insur- waded to the ent live us written of an "occur- iay result in a such notice J CG D2 46 08 05 © 2005 The St Paul Travelers Companies, Inc 015979 Page 1 of 2 COMMERCIAL GENERAL LIABILITY i How, when and where the "occurrence" or offense took place, u The names and addresses of any injured persons and witnesses, and ui 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 u 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 insuranc ' which would cover the additional insured f r a loss we cover under this endorsement owever, this condition does not affect whet er the insur- ance provided to the addition I insured by this endorsement is primary t "other insur- ance" available to the adds onal insured which covers that person or org nization as a named insured as described in paragraph 3 above 5 The following definition is added tq SECTION V — DEFINITIONS "Written contract requiring insurance" means that part of any written contractl or agreement under which you are requireq to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "propertyyy damage" oc- curs and the "personal injury" i$ caused by an offense committed a After the signing and E contract or agreement b While that part of t agreement is in effect, c. Before the end of the i :ution of the you, contract or period Page 2 of 2 © 2005 The St Paul Travelers Companies, Inc CG D2 46 08 05