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HomeMy WebLinkAboutDON KEHN - INSURANCE CERTIFICATE (2)cuenta tZZIU ouvl1JnrHA1 ACORD- CERTIFICATE OF LIABILITY INSURANCE 1DATE 0/30/07 (MMIDDNYYY) PRODUCER HRH of Colorado 720 South Colorado Boulevard Suite 60ON Denver, CO 80246 Don Kehn Construction, Inc 6550 SCR5 Fort Collins, CO 80528 COVERAGES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW INSURERS AFFORDING COVERAGE NAIC # INSURER Travelers Indemnity Company 25658 INSURER B Travelers Property Casualty Company 36161 INSURERC PmnacolAssurance 41190 INSURER D INSURER E 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH rHIS CERTIFICATE MAYBE 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 DD NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MMIDDIY\' LIMITS A GENERAL LIABILITY C0161E88931ND 11/01/07 11/01/08 EACH OCCURRENCE $1000000 PRMMIS T Ed... ENTDeuce s300 OOO' COMMERCIAL GENERAL LIABILITY MED EXP(My one person) $5000 CLAIMS MADEOCCUR PERSONAL 8 ADV INJURY $1 000 000 AI# CG D2 46 08/05 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG 52 000 00O POLICY X JEQ LOG B AUTOMOBILE LIABILITY ANY AUTO 810161E8893TIL 11/01/07 11/01/08 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) S HIRED AUTOS NON OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN EA ACC S ANY AUTO S AUTOONLY AGG B EXCESSIUMBRELLA LIABILITY CUP161E8893TIL 11/01/07 11/01/08 EACH OCCURRENCE $2000000 AGGREGATE s2,000,000 X OCCUR 7 CLAIMS MADE $ $ DEDUCTIBLE $ X RETENTION $ 10 000 C WORKERS COMPENSATION AND 2093950 10I01/07 10/01/08 OTH X WC STATU 11 E L EACH ACCIDENT s500000 EMPLOYERS LIABILITY ANY PROPRIETORPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? EL DISEASE EA EMPLOYEE $500,000 Syes tlescnbe intler SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description Mining Reclamation Agreement regarding Arapahoe Bend Natural Area (See Attached Descriptions) City of Ft Collins PO Box 580 Fort Collins, CO 80522-0580 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL an, DAYS WRITTEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO 00 SO SHALL ;E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR ACORD 25 (2001/08) 1 of 3 #M558580 SMSTY © ACORD CORPORATION 198 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 indemnify 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 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 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 insurer(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 2" (2001/09) 2 of 3 #M558580 DtSCRIPTIONS'(Continued from,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 AMS 25 3 (2001108) 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 ll) 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 equiring insurance" specifically requires you a) Only with respect to liability for "bodily injury", to provide such coverage for that additional "property damage" or "personal injury"; and insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only 10 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 Pad 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" available to the additional insured which covers surance". This endorsement shall not in- that person or organization as a named insured =_ crease the limits of insurance described in for such. loss, and we will not share with that Section III —Limits Of Insurance. "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 not 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 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, a) The additional insured must give us written approving, or failing to prepare or ap- notice as soon as practicable of an "occur- prove, drawings and specifications: and 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 02 46;08 05 © 2005 The St. Paul Travelers Companies, Inc. Paoe t 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 clairn is made or "suit" is brought against the additional insured, the additional insured must: c) m 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. 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. The additional insured must lender the de- i'ense 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. PauhTravelers Companies, Inc. CG D2 46 08 05 ACORDTM CERTIFICATE OF LIABILITY INSURANCE 10/30/07 Dmvr 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 INSURER A Travelers Indemnity Company 25658 Don Kehn Construction, Inc INSURER Travelers Property Casualty Company 36161 6550 SCRS 1INSURERG Pinnacol Assurance 41190 Fort Collins, CO 80528 INSURERD NSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 0 NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIVY POLICY EXPIRATIO N DATE MMIDD/Yl' LIMITS A GENERAL LIABILITY C0161E88931ND 11/01/07 11/01/08 EACH OCCURRENCE $1000000 DAMAGE TO RENTED EMI S a rren $300.000 COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $5 000 CLAIMS MADE a OCCUR PERSONAL s ADV INJURY $1 000 000 AI# C0 D2 46 08/05 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2000000 17 POLICY X I'M El LOG B AUTOMOBILE LIABILITY ANY AUTO 810161E8893TIL 11/01/07 11/01/08 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X 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 S AUTO ONLY AGG B EXCESSIUM13RELLALIABILITY CUP161EB893TIL 11/01/07 11/01/08 EACH OCCURRENCE $2000000 AGGREGATE s2,000,000 X OCCUR F7 CLAIMS MADE S $ DEDUCTIBLE S X RETENTION $ 1O 000 C WORKERS COMPENSATION AND 2093950 10/01/07 10/01/08 X WC STAI'T OTH- E L EACH ACCIDENT $SOO OOO EMPLOYERS LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED' EL DISEASE - EA EMPLOYEE S500,000 It yes describe under SPECIAL PROVISIONS be. 1 EL DISEASE -POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description Bid 5958 East Prospect Road Improvements (See Attached Descriptions) City of Fort Collins 215 North Mason Street, 2nd Floor PO Box 580 Fort Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF THE ISSUING INSUREP WILL ENDEAVOR TO MAIL 3n, DAYSWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR ACORD 26 (2001/08) 1 of 3 #M558580 AUTHORIZED BMSTY a ACORD CORPORATION 198 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 insurer(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 (Cornfinued from Paige 1 j � 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 AMS 25 3 (2001/08) 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 I. 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: 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 the additional in- sured does not apply to "bodily Injury" or "property damage" caused by "your work" and induced in the "products -completed op- erations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 3. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible "other insurance", whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply an a primary basis or a primary, and non-contributory basis, this insurance :s primary to "other Insurance„ available to the additional insured which covers that person or organization as a named insured for such loss, and we will not share with that "other insurance". But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible "other in- surance", whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured when that person or organization is an additional insured under such "other insur- ance". 4. As a condition of coverage provided to the additional irsured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an "occur- rence" or an offense which may result in a claim. To the extent possible such notice should include: CG D2 46 08 05 © 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2