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Home My WebLink AboutDON KEHN CONSTRUCTION - INSURANCE CERTIFICATE (6)ACORD- INSURANCE (MWDDNYM CERTIFICATE OF LIABILITY 0DATE 9/22/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 720 S. Colorado Blvd Ste 600-N ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 469025 Denver, CO 80246-9025 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Indemnity Company 25658 Don Kahn Construction, Inc. INSURER B: Pinnacol Assurance 10780 6550 SCRS INSURER C: Fort Collins, CO 80528 INSURER D: INSURER 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 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 DD NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM DD POLICY EXPIRATION DATE MM DO LIMBS A GENERAL LIABILITY DTC0161E8893IND03 11/01/03 11/01/04 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTPREMISE Me .ED $300 000 CLAIMS MADE a OCCUR MED EXP (Any one person) $10 000 PERSONAL B ADV INJURY $1 000 000 X Blkt Addl lnsrd X Ltd Pollution GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2000000 PX PRO OLICY - JECT X LOC , A AUTOMOBILE LIABILITY ANY AUTO DT810161E8893TIL ,J _ `r )y1 ��$l ,, i �_ r uiu i '� COMBINED SINGLE LIMIT (Ea accident) 000 $1 r r000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS SEP «C, ' : (( OY X BODILY INJURY (Per accident) $ X Ltd Pollution CIT RISK OF FOk 1 C pIV9,( A T _C U LINS FNJI X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESSIUMBRELLALIABILITY DTSMJCLIP161E8893TI 11/01/03 11/01/04 EACH OCCURRENCE $2000000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ DEDUCTIBLE $ X RETENTION $10000 WORKERS COMPENSATION AND 2093950 10/01/04 10/01/05 - X WC STATU- OTHEEL UMITB EMPLOYERS' LIABILITY ANY PROPRIETORMARTNER/EXECUTIVE E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEEI s500,000 OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E-L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Project Description: Furnishing Asphalt The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects (See Attached Descriptions) City of Ft. Collins ATTN: Director of Purchasing & Risk Management P. O. Box 580 Ft. Collins, CO 80522-0580 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Mtn* DAYS WRITTEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL iE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVE e+ Wv v 14 tcvu IIYOI 7 OT 4 SMZL3`Jl/L HXK U AGUKU GUKYUKAI IUN lsiftl 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. AGORD 25-5 (20MMU) 2 of 3 #M223972 DESCRIPTIONS (Continued frontPage 'I) work performed by the Insured for the Additional Insureds. All coverage terms, conditions and exclusions of the policy apply. Additional Insureds: City of Ft. Collins 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 rams za.s kzuuTrue) 3 oT 3 1VMTl397Z Policy Number: DI-Co-16IE889.3-IND--03 COMMERCIAL GENERAL LIABILITY HIS En;nn �EnnEr,iT CHANIGES THE enLlCy. PLE^-E RE^tiD IT CAR -FULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY- CONTRACTORS COVERAGE PART 1. WHO IS AN INSURED - (Section II) is amended c) This insurance does not apply to "bodily in- to include any person or organization you are re- jury" or "property damage" caused by "your quired to include as an additional insured on this work" included . in the "products -completed policy by a written contract or written agreement operations hazard" unless you are required to in effect during this policy period and signed and provide such coverage for the additional in - executed by you prior to the loss for which cover- sured by a written contract or written agree - age is sought. The person or organization does ment in effect during this policy period and not qualify as an additional insured with respect to signed and executed by you prior to the loss the independent acts or omissions of such person for which coverage is sought and then only o�organization. The_Qe_ -son or organization is for the period of time required by such con - only an additional insured with respect to liability tract or agreement and in no event beyond caused by "your work" for that additional insured. the expiration date of the policy. 2. The insurance provided to the additional insured > is limited as follows: a) In the event that the limits of liability stated in - the policy exceed the limits of liability required by a written contract or written agreement in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought, the insurance provided by this endorsement shall be limited to the limits of liability required by such contract or agreement. This endorsement shall not in - a.= crease the limits stated in Section III - LIMITS OF INSURANCE. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage", "personal injury" or "advertising injury" arising out of an architect's, engineer's or surveyor's rendering of or failure to render �-= any professional services including: 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifi- cations; and 11. Supeniisory or inspection activities per -formed as part of any related architectural or enaineering activities. 3. Subpart (1)(a) of the Pollution exclusion under Paragraph 2., Exclusions of Bodily Injury and Property Damage Liability Coverage (Section I - Coverages) does not apply to you if the "bodily injury" or "property damage" arises out of "your work" performed on premises which are owned or rented by the additional insured at the time "your work" is performed. 4. Any coverage provided by this endorsement to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, con- tingent or on any other basis unless a written contract or written agreement in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought specifically requires that this insurance apply on a primary or non-contributory basis. When this in- surance is primary and there is other insurance available to the additional insured from any source, we will share with that other insurance by the method described in the policy. S. As a condition of coverage, each additional insured must: a.) Give us prompt written notice of any "occur- rence" or offense which may result in a claim and prompt written notice of "suit". "� ;n ..Jji'yfl(j ilt ThV Tl ab ::i:: re indei7ridy'—ump6fly, 2002 Peggy .I `:f'-