HomeMy WebLinkAboutCORRESPONDENCE - GENERAL CORRESPONDENCE - INSURANCE CERTIFICATEACORD CERTIFICATE OF LIABILITY INSURANCE OP ID D DATE (MMIDD YY)
LTZ-1 02/04/03
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Brown & Brown Inc - Ft Collins HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
125 S Howes 5th Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Fort Collins CO 80522-226
Phone:970-482-7747 Fax:970-484-4165
INSURED
Goltz Asphalt Company
Attn: Dave
3724 Larkspur Dr
Loveland CD 80538
COVERAGES
INSURERS AFFORDING COVERAGE
INSURERA: UNITED FIRE & CASUALTY
INSURERB: Pinnacol Assurance
INSURER C:
INSURER D:
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.
INSRI TYPE OF INSURANCE
LTR'
POLICY NUMBER
POLICY EFFECTIVE
DATE MMIDDIYY
POLICY EXPIRATION
DATE MMIDDIYV
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR
60075813
02/02/03
02/02/04
EACH OCCURRENCE
$ 1,000,000
FIRE DAMAGE (Any one fire)
$100,000
MED EXP (Any one person)
s5,000
PERSONAL B ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GEML AGGREGATE LIMIT APPLIES PER:
X POLICY PRO LOC
JECT
PRODUCTS - COMP/OP AGG
s2,000,000
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULEDAUTOS
HIREDAUTOS
NON -OWNED AUTOS
60075813
02/02/03
02/02/04
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
BODILY INJURY
(Per person)
$
X
X
BODILY INJURY
(Per accident)
$
X
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
A
EXCESS LIABILITY
X OCCUR CLAIMS MADE
DEDUCTIBLE
X RETENTION $ 10 , 000
60075813
1
02/02/03
02/02/04
EACH OCCURRENCE
$ $1 , 000 , 000
AGGREGATE
$$1,000,000
$
$
$
WORKERS COMPENSATION AND
B EMPLOYERS' LIABILITY
'..
4055471
04/10/02
04/01/03
X TORY LIMITS I ER
E.L. EACH ACCIDENT
$500000
E.L. DISEASE - EA EMPLOYEE
$ 500 , OOO
E.L. DISEASE -POLICY LIMIT
1 $500,000
OTHER
A 'Hired/Rented Equip
IS ecial Form
60075813
02/02/03
02/02/04
$150,000 Any One Ite
$500 Deductible
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
fall I IFIL'A I t MULUEK I N I ADDITIONAL INSURED- INSIIRFR I FTTFR• CANCFI I ATION
FTCCITY
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF FORT COLLINS
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
WATER UTILITIES
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
ATTN: OPAL
PO BOX 580
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
FORT COLLINS CO 80522-0580
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE "- ( • n
MVVRU 4G-Q k1full VAUOKU UORPORATION 1983