HomeMy WebLinkAbout437747 R & D VENDING (ROGER D SORENSEN) - INSURANCE CERTIFICATE (3)Policy Number DECLARATIONS PAGE AMENDED OCT 29 2007 O
96-E9-9212-2
STATE FARM FIRE AND CASUALTY COMPANY
1555 PROMONTORY CIRCLE, GREELEY CO 80638-0001
-� A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
Named Insured and Mailing Address
20-1508-F913 T 2
SORENSEN, ROGER D
IDEA R & D VENDING
2300 SILVER TRAILS DR
FORT COLLINS CO 80526-6418
Cov A - Inflation Coverage Index: N/A
BUSINESS POLICY - SPECIAL FORM 3 Cov B - Consumer Price Index: 208.4
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this folic will be renewed automatically
subject to the premiums, rules and forms in effect for each succeeding policy perioi. If this policy is terminated, we will
give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions, or as required by law.
Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the
Effective Date: OCT 5 2007 premises location.
Expiration Date: OCT 5 2008
Location of Covered Premises:
2300 SILVER TRAILS DR
FORT COLLINS CO 80526-6418
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products -Completed Operations
(PCO) Aggregate
General Aggregate (Other
Than PCO)
Forms, Options, and Endorsements
Special Form 3
'Section II Additional Insured
Amendatory Endorsement
Tree Debris Removal
Business Policy Endorsement
Glass Deductible Deletion
Inland Marine Attaching Dec
New Form Attached
Limits of Insurance
Excluded
4,800
Actual Loss
1,000,000
5,000
2,000,000
2,000,000
FP-6103
FE-6609
FE-6206.1
FE-6451
FE-6464
FE-6538.1
FE-8750
Continued on Reverse Side of Page
Prepared OTHER LIMITS AND EXCLUSIONS M
NOV 01 2007 Cou
Your policy is amended OCT 29 2007
ADDL INSURED NAME & ADDRESS ADDED
PREMIUM ADJUSTMENT
ENDORSEMENT FE-6609 ADDED
Deductibles - Section I
$ 500 Basic
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
Endorsement Premium
Increase $ 37.36
Discounts Applied:
Renewal Year
Years in Bu_Igtess
,j Claimdoord ice p
S�atie ` 69e 0 \ aac gp52.�
) OGc\w-15",223'9App-
FP-8030.2C SK93
06/1993
Your policy consists of this page, any endorsements
and the policy form. PLEASE KEEP THESE TOGETHER.
nt
(olf2172b)
Policy Number
96-E9-9212-2
CONTINUED FROM FRONT SIDE
BUSINESS POLICY - SPECIAL FORM 3
Forms,Options,and Endorsements
Inland Marine Conditions
FE-8751
Loss Payable Endorsement
FE-6309
Additional Insured Endorsement
FE-6494
Vending Machine Form
FE-8764
Fungus (Including Mold) Excl
FE-6566
Inc Cost and Demolition Cov
FE-6587
Policy Endorsement - Business
FE-6610
Terrorism Insurance Gov Notice
FE-6999
Dist Mat Violat Statues Excl
FE-6655
Policy Endorsement
FE-6656
Policy Endorsement - Business
FE-6851
Money/Securities
Option MO
$2,000/$2,000
O'*
Prepared
NOV 01 2007
(o 1@175a)
FE-6609
Page 1 of 1
SECTION II ADDITIONAL INSURED ENDORSEMENT
Policy No 96-E9-9212-2
Named Insured:
SORENSEN, ROGER D
DBA R & D VENDING
2300 SILVER TRAILS DR
FORT COLLINS CO 80526-6418
Additional Insured (mcllude address)
THE CITY OF FORT COLLINS
215 N MASON ST
FORT COLLINS CO 80524-4402
WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the
Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely because
of your work performed for that Additional Insured shown above
Any insurance provided to the Additional Insured shall only apply with respect to a claim made or suit brought for
damages for which you are provided coverage
The Primary Insurance coverage below applies only when there is an "X' in the box
❑ Primary Insurance The insurance provided to the Additional Insured shown above shall be primary insurance
Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to
you
All other provisions of the policy apply
FE-6609