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HomeMy WebLinkAboutDON KEHN CONSTRUCTION - INSURANCE CERTIFICATE (4)(`Ibnnrd! c1010 REC)N KF H NI ACORQv CERTIFICATE OF LIABILITY INSURANCE 3010/DDIY YV) D01Tr 10/30/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado 720 South Colorado Boulevard ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIL # INSURED Don Kehn Construction, Inc 6550 SCR5 Fort Collins, CO 80528 INSURER A Travelers Indemnity Company 25658 INSURER B Travelers Property Casualty Company 36161 INSURERC Pmnacol Assurance 41190 INSURER D INSURER E COVFRAGFS 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSLTR SR NS TYPE OF INSURANCE POLICY NUMBER DATEVMMDDIYYE POL DATE MMIOIYYN LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR AI# CG D2 46 08105 C0161E88931ND 11/01/07 11/01/08 EACH OCCURRENCE $1000000 PREMIEETOEa occurance $300000 MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 000 000 X Ltd Pollution GENERAL AGGREGATE $2 000 000 GEN L AGGREGATE LIMIT APPLIES PER POLICY X JECOT IOC PRODUCTS COMP/OPAGG B AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS AUTOS HIRED AUTOSBODILY NON OWNED AUTOS Ltd Pollution 810161EB893TIL 11/01/07 11/01/08 COMBINED SINGLE LIMIT (Ea accident) r$2OOOOOO ,000ALL X BODILY INJURYSCHEDULED (Per person) X INJURY (Per accident) X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTOONLV EAACCIDENT $ OTHERTHAN EA ACC AUTO ONLY AGG $ $ B EXCESS/UMBRELLA LIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE X RETENTION $ 10,000 CUP161EB893TIL 11/01/07 11/01/08 EACH OCCURRENCE $2000000 AGGREGATE s2,000000 $ $ C WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED' If yes describe under SPECIAL PROVISIONS below 2093950 10101/07 10/01/08 TAT X WC LIMIT OTH EL EACH ACCIDENT $SOO,000 E L DISEASE EA EMPLOYEE s500.000 E L DISEASE POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS] VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description Furnishing Asphalt (See Attached Descriptions) City of Ft Collins ATTN Director of Pul chasing & Risk Management P O Box 580 Ft Collins, CO 80522-0580 LD ANY OF THE ABOVE OESCRI13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3n' DAYSWRITTEN £ TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ENO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ACnan gs Mnnd/nRi , -, R MN,IGGoeon RIu1QTV 0 ACORD CORPORATION 1929 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 in. 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 Bairn 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 riot 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 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed A statement 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 may require an endorsement A statement on this certificate does not confer lights to the certificate 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 rnsuier(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 thereon ACORD 25S 12001108) 2 of 3 #M558580 DESCRIPTIONS,(Continued'f�r#o►n Page 1) The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects 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 e AMS 25 3 12001/08) 3 of 3 #M5585E COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY 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 c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products -completed op - age Part, but: erations hazard" unless the "written contract a) Only with respect to liability for "bodily injury", requiring insurance" specifically requires you "property damage" or "personal injury", and to provide such coverage for that additional insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only to such damage is caused by acts or omissions of "bodily injury" or "property damage" that oc- you or your subcontractor in the performance curs before the end of the period of time for of "your work" to which the "written contract which the "written contract requiring insur- requiring insurance" applies. The person or ante" requires you to provide such coverage organization does not qualify as an additional or the end of the policy period, whichever is insured with respect to the independent acts earlier. or omissions of such person or organization. 3. The insurance provided to the additional insured 2. The insurance provided to the additional insured by this endorsement is excess over any valid and by this endorsement is limited as follows: collectible "other insurance", whether primary, a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is this Coverage Part shown in the Declarations available to the additional insured for a loss we —_ exceed the limits of liability required by the cover under this endorsement. However, if the "written contract requiring insurance", the in- "written contract requiring insurance" specifically surance provided to the additional insured requires that this insurance apply on a primary —_ shall be limited to the limits of liability re- basis or a primary and non-contributory basis, -= quired by that "written contract requiring in- this insurance is primary to "other insurance" surance". This endorsement shall not in- available to the additional insured which covers =_ crease the limits of insurance described in that person or organization as a named insured =_ Section III - Limits Of Insurance. for such, loss, and we will not share with that "other insurance". But the insurance provided to b) The insurance provided to the additional in- e a the additional insured by this endorsement still is shred does not apply "bodily u "prop- pp y injury", p p- excess over any valid and collectible "other in- erty damage" or "personal injury" arising out surance", whether primary, excess, contingent or of the rendering of, or failure to render, any on any other basis, that is available to the addi- professional architectural, engineering or sur- tional insured when that person or organization is veying services, including: an additional insured under such "other insur- _ i. The preparing, approving, or failing to ante", prepare or approve, maps, shop draw- 4. As a condition of coverage provided to the ings, opinions, reports, surveys, field or - additional insured by this endorsement: -= ders or change orders, or the preparing, —_ approving, or failing to prepare or ap- a) The additional insured must give us written prove, drawings and specifications; and notice as soon as practicable of an "occur- rence" or an offense which may result In a Supervisory, inspection, architectural or claim. To the exient possible.. such notice engineering activities. should include CG D2 46 08 05 © 2005 The St. Paul Travelers Companies, Inc. Pace 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: L 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 lender the de- fense and indemnity of any claim or "snit" to any provider of "other. insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does riot 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 Client# 52210 8DONKEHN ACORUD CERTIFICATE OF LIABILITY INSURANCE 10/30/07D/YYYYI 0/30/ 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, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIC # INSURED Don Kehn Construction, Inc 6550 SCRS Fort Collins, CO 80528 INSURER A Travelers Indemnity Company 25658 INSURER B Travelers Property Casualty Company 36161 INsuRER c Pmnacol Assurance 41190 INSURERD INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED 13E LOW 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR ADD L INSRE TYPE OF INSURANCE POLICY NUMBER POLOYEFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MMlDDIYY LIMITS A GENERAL LIABILITY C0161E8893IND 11/01/07 11/01/08 EACH OCCURRENCE $1000000 COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR DAMAGPREMSES(Ea occTO urrence s3000OO MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 000 OQO AI# CG D2 46 08/05 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN L AGGREGATE LI MIT APPLIESPER PRODUCTS COMPIOPAGG $2000000 POLICY X PRO T LOC B AUTOMOBILE LIABILITY ANY AUTO 810161E8893TIL 11/01/07 11/01/08 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X IX BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution — GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY AGO B EXCESSIUMBRELLA LIABILITY CUP161EB893TIL 11/01/07 11/01/08 EACH OCCURRENCE $2000000 X I OCCUR CLAIMS MODE AGGREGATE s2,000,000 $ S DEDUCTIBLE $ X RETENTION $ 10 000 C WORKERS COMPENSATION AND 2093950 10/01/07 10/01/08 X WC STATU OTH- EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT s500,000 EL DISEASE EA EMPLOYEE $500,000 OFFICERIMEMBER EXCLUDED' If yes describe under SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description 6045 Asphalt Supply (See Attached Descriptions) City of Fort Collins Administrative Services Purchasing Division PO Box 580 Fort Collins, CO 80522-0580 LID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL zn' DAYS WRITTEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL IS NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR �i-vKu m icuvlma) 1 or 3 #M558580 8MSTY W AI UKU wrarurw I PUN TBtlEf IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed A statement 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 may require an endorsement A statement on this certificate does not confer rights to the certificate 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 insuier(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 thereon ACORD 25-S (2001108) 2 of 3 #M558580 DESCRIPTIONS"(Contirided,from'Page 1),I The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects work performed by the Insured for the Additional Insureds All coverage terms, conditions and exclusions of the policy apply Additional Insureds City of Forl 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 AM5 25 3 )2UUI/UU) 3 Of 3 #M558580 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY 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 c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products -completed op - age Part, but: erations hazard" unless the "written contract a) Only with respect to liability for "bodily injury", requiring insurance" specifically requires you "property damage" or "personal injury", and to provide such coverage for that additional insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only to such damage is caused by acts or omissions of "bodily injury" or "property damage" that oc- you or your subcontractor in the performance curs before the end of the period of time for of "your work" to which the "written contract which the "written contract requiring insur- requiring insurance" applies. The person or ance" requires you to provide such coverage organization does not qualify as an additional or the end of the policy period, whichever is insured with respect to the independent acts earlier, or omissions of such person or organization. 3. The insurance provided to the additional insured 2. The insurance provided to the additional insured by this endorsement is excess over any valid and by this endorsement is limited as follows: collectible "other insurance", whether primary, a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is this Coverage Part shown in the Declarations available to the additional insured for a loss we exceed the limits of liability required by the cover under this endorsement. However, if the "written contract requiring insurance", the in- "written contract requiring insurance" specifically surance provided to the additional insured requires that this insurance apply on a primary shall be limited to the limits of liability re- basis or a primary and non-contributory basis, -= quired by that "writier, contract requiring in- this insurance is primary to 'other insurance" surance". This endorsement shall not in- available to the additional insured which covers =_ crease the limits of insurance described in that person or organization as a named insured = Section III - Limits Of Insurance. for such loss, and we will not share with that "other insurance". But the insurance provided to b) The insurance provided to the additional in- the additional insured by this endorsement still is sured does riot apply to "bodily injury", "prop- excess over any valid and collectible "other in- erty damage" or "personal injury" arising out surance", whether primary, excess, contingent or of the rendering of, or failure to render, any on any other basis, that is available to the addi- professional architectural, engineering or sur- tional insured when that person or organization is —_ veying services, including: an additional insured under such "other insur- _ i. The preparing, approving, or failing to once", prepare or approve, maps, shop draw- 4. As a condition of coverage provided to the ings, opinions, reports, surveys, field or additional insured by this endorsement: -= ders or change orders, or the preparing, — a ) The additional insured must give us written approving, or failing to prepare or ap- prove., drawings and specifications: and notice as soon as practicable of an "occur- = rence" or an offense which may result in a ii. Supervisory, inspection, architectural or claim. To the extent possible. such notice engineering activities. should include: CG D2 46 08 05 © 2005 The St. maul Travelers Companies, Inc. Paoe 1 of 2