HomeMy WebLinkAboutAPPLE ANNIES - INSURANCE CERTIFICATEACORD*� CERTIFICATE OF LIABILITY INSURANCE
MID6/O004
06/01/2004)
PRODUCER (970) 484-2805
John C. Beckett 6 Associates, Inc.
220 Smith Street
Ft. Collins CO 80524-
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
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 #
INSURED
NELSON SCHROEDER ENTERPRISES, INC DBA
APPLE ANNIE' S WASHHOUSE
1119 W. DRAJKE C-40
FT COLLINS CO 80526-6030
INSURER A:MARYLAND CASUALTY COMPANY
INSURER B: PINNACOL ASSURANCE
INSURER C:
INSURER D:
INSURER E:
n 11..1vc
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
ADD'L
INSRO
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MWOD
POLICY EXPIRATION
DATE MWDD
LIMITS
A
GENERAL LIABILITY
/ /
/ /
EACH OCCURRENCE
$ 1,000,000
X COMMERCIAL GENERAL LIABILITY
GE
PRA M SES EaENTED oaurrence
8 1,000,000
CLAIMS MADE a OCCUR
PPS034903949
05/07/2003
05/07/2004
MED EXP (Any oneperson)
S 10,000
PERSONAL& ADV INJURY
S 1,000,000
05/07/2004
05/07/2005
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO
S 2,000,000
X POLICY JECT LOC
A
AUTOMOBILE
LIABILITY
ANY AUTO
/ /
/ /
COMBINED SINGLE LIMIT
(Ea accident)
a 500,000
X
BODILYINJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
PPS034903949
05/07/2003
05/07/2004
BODILYINJURY
(Per accident)
S
HIRED AUTOS
NON -OWNED AUTOS
05/07/2004
05/07/2005
PROPERTY DAMAGE
(Per accident)
S
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
S
ANY AUTO
NO COVERAGE
/ /
/ /
S
AUTO ONLY: AGO
EXCESSIUMBRELLA LIABILITY
NO COVERAGE
/ /
/ /
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
6
$
DEDUCTIBLE
/ /
/ /
ItCC
RETENTION $
B
WORKERS COMPENSATION AND
PENDING
05/21/2004
06/01/2005
gg uu -
X TORYLIMITS I ER
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE
E.L. EACH ACCIDENT
S 100,000
E.L. DISEASE - EA EMPLOYEE
$ 100,000
OFFICER/MEMBER EXCLUDED?
/ /
/ /
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
8 500 , 000
OTHER
NO COVERAGE
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
THIS CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL INSURED IN RESPECT TO THE GENERAL LIABILITY.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
CITY OF FT. COLLINS FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILRY OF ANY KIND UPON THE
PO BOX 580 INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
FORT COLLINS CO 80522—� �—
Ar-nen 25 fsnouom ® ACORD CORPORATION 1988
AT. INS025 (0108).05 ELECTRONIC LASER FORMS, INC. - (800)327.0545 Page 1 of 2
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.
AGVRD 25 (Z001105)
INS025 (=8).os Page 2 of 2