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Home My WebLink AboutROBERTS EXCAVATION CORPORATION - INSURANCE CERTIFICATE (4)From: Tor! Griscavage At: Brown & Brown of Colorado FaxID: (970) 484-4165 To: City of Fart Collins Date: 4162011 01:13 PM Page: 2 of 2 AJOKH CERTIFICATE OF LIABILITY INSURANCE OPID TO DATEAJE�04/06/11 � 04/06/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the po cy es must be endorsed. 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). PRODUCER Brown S Brown Inc NAME: PHONE WC. No. EM: (NG. No): 125 S Howes, Sth Floor ADDRESS: P O BOX 2226 Fort Collins CO 80522-2226 CUSTOMERID*. ROBER-7 Phone:970-482-7747 Fax:970-484-4165 INSURERIS) AFFORDING COVERAGE NAIC1 INSURED INSURER A: Mountain States Mutual 14648 Roberts Excavation Corporation Attn: Gerald Roberts INSURER B: Pinnacol Assurance Company 41190 INSURER C: 1801 1st Street Berthoud CO $0513 INSURER D: INSURER E' INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY MAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED PROVE FOR THE POLICY PERIOD INDICATED. NO1WITHSTANDINGANYREOUIREMENT,TERMORCONDITIONOFANYCO4iRACTOROTHERD000MENTWITHRESPECTTOWHICHi is 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR TYPE OF INSURANCE eJSR POLICY NUMBER (MMIDD1ITYY) (MMIDDA9YYEx"I LIMITS GENERAL LIABILITY EACH OCCURRENCE I$1,000,000 A X COMMERCIAL GENERAL LIPBILITY CPP011975706 04/01/11 04/01/12 PREMISES(Ee occvrpnce) E 100, 000 CLAMS -MADE F—xl OCCUR MED EXP (My one person) $ 10 , OOO PERSONAL & ADV INJURY E 1 , 000 , 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E2,000,000 POLICY n PRO-LOCJECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIN11T $1r000,000 A X ANY AUTO BAP011475705 04/01/11 04/01/12 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILYINJURY(Pareccidenp — 'E SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident S NON -OWNED AUTOS $ $ A X UMBRELLA LIAR X OCCUR UMB011475705 04/01/11 04/01/12 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADEGR 'GC" E1,000,OOO DEDUCTIBLE Is X RETENTION S 0 E B3241433 AND EMPLOYERSLIABILITY Y J N I 06/01/10 06/01/11 X TORY LIMITS VER EL. EACII.ACCICENT $ S,000,OOO MY PROPRIETOR/P�CURVE OFFICERIMEMBER EXCLLAEDO NIA E.L. DISEASE-EAEAIPLOYEE $ 1,000,000 (Mandatory In NH) II yes, d .ribe UnJer DESCRIPTION OF OPERATIONS below EL. DISEASE-POUCYLIMIi 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Adorn .nal Remark, Sohedule, if more ,pac, i, -,nand) Fax# 221-6707 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYFIO I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins 215.N^ Mason St. ^w'^ George W Alcorn 01988-2009 ACORD ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD From: Tor! Griscavage At: Brown & Brown of Colorado FaxID: (970) 484-4165 To: City of Fart Collins Date: 4162011 01:13 PM Page: 2 of 2 AJOKH CERTIFICATE OF LIABILITY INSURANCE OPID TO DATEAJE�04/06/11 � 04/06/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the po cy es must be endorsed. 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). PRODUCER Brown S Brown Inc NAME: PHONE WC. No. EM: (NG. No): 125 S Howes, Sth Floor ADDRESS: P O BOX 2226 Fort Collins CO 80522-2226 CUSTOMERID*. ROBER-7 Phone:970-482-7747 Fax:970-484-4165 INSURERIS) AFFORDING COVERAGE NAIC1 INSURED INSURER A: Mountain States Mutual 14648 Roberts Excavation Corporation Attn: Gerald Roberts INSURER B: Pinnacol Assurance Company 41190 INSURER C: 1801 1st Street Berthoud CO $0513 INSURER D: INSURER E' INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY MAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED PROVE FOR THE POLICY PERIOD INDICATED. NO1WITHSTANDINGANYREOUIREMENT,TERMORCONDITIONOFANYCO4iRACTOROTHERD000MENTWITHRESPECTTOWHICHi is 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR TYPE OF INSURANCE eJSR POLICY NUMBER (MMIDD1ITYY) (MMIDDA9YYEx"I LIMITS GENERAL LIABILITY EACH OCCURRENCE I$1,000,000 A X COMMERCIAL GENERAL LIPBILITY CPP011975706 04/01/11 04/01/12 PREMISES(Ee occvrpnce) E 100, 000 CLAMS -MADE F—xl OCCUR MED EXP (My one person) $ 10 , OOO PERSONAL & ADV INJURY E 1 , 000 , 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E2,000,000 POLICY n PRO-LOCJECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIN11T $1r000,000 A X ANY AUTO BAP011475705 04/01/11 04/01/12 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILYINJURY(Pareccidenp — 'E SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident S NON -OWNED AUTOS $ $ A X UMBRELLA LIAR X OCCUR UMB011475705 04/01/11 04/01/12 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADEGR 'GC" E1,000,OOO DEDUCTIBLE Is X RETENTION S 0 E B3241433 AND EMPLOYERSLIABILITY Y J N I 06/01/10 06/01/11 X TORY LIMITS VER EL. EACII.ACCICENT $ S,000,OOO MY PROPRIETOR/P�CURVE OFFICERIMEMBER EXCLLAEDO NIA E.L. DISEASE-EAEAIPLOYEE $ 1,000,000 (Mandatory In NH) II yes, d .ribe UnJer DESCRIPTION OF OPERATIONS below EL. DISEASE-POUCYLIMIi 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Adorn .nal Remark, Sohedule, if more ,pac, i, -,nand) Fax# 221-6707 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYFIO I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins 215.N^ Mason St. ^w'^ George W Alcorn 01988-2009 ACORD ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD