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HomeMy WebLinkAboutAPEX ROOTER PLUMBING - INSURANCE CERTIFICATEgCORD CERTIFICATE OF LIABILITY INSURANCE APOP 1 °"ii ire o PRooucIR TM CERWICATE Is ISSUED As A OF IN oRMAn ONLY AND CONFERS NO R1G TS UPON THE CERTIFICATE Rix Insurance Associates, Inc. HOLDER. TMS; CERTIFICATE DOES NOT AMEND, EXTEND O 4440 Arapahoe Ave., Ste 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELC Boulder CO 80303 Phone: 303-444-4666 lax: 303-444-84 ;) INSURERS AFFORDING COVERAGE NAIC / ®Q • MBURl9tA Pinnacol Assurance • �' rNeuRel e rRooter & Pltmbtnq a 33 Co Rooter it Fort Inc MISLX03t Col s 00 OS21 r o B6lR6lE MAD 1 7 -)nnr THE POLICES OF NSURANCE LISTS BELOW HAVE BEEN ISSUED TO THE INSURED f WAED ABOVE FOR THE POLWV I INDK`AM. N011MTHST/1 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCWAIEHR WITH RESPECT TO WHICH TNI EJGffi MAY PERTAIN, THE NSV%4NCE AFFORDED BY THE POLICES OES(MMI IEREN 6 S AE= TO ALL THE TERMS, EXCLUSIONS AND CO POUFS. AGOREG114TE LMTS SHOWN MAY HAVE BEEN REDUCED SY PADCLAW S. LTA TINE OF INSURANCE POLICY MItlBE[ OA LIMITS GENERAL LIABaJTY GMAH1QAt.O86iAL LYIBLITY CLAMS MADE OCCUR EACH OCCURRENCE $ pRg .• aCHa®if a!• S M® EXP WW arm pram S PERSONAL a ADV IHLAIRY s GENERAL AGGREGATE $ GEHL AGGREGATE LIMIT APPLES PER: POLICY LOC PRODUCTS -COMPIOP AGO S AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS FIRED AUTOS NON-0VYI� AUTOS COMINNED SINGLE LMRT LEaamm 4 a BOOILYHRRY (Parpraoa> s YINARY BO s DAMAGE s CARAGELLABILRY ANY AM AUTTOONLY-EAAOCIDQtT S OhEFITHAN EAACC AUmomy: AM S S E%CESSAMBFJBJALIABEM OCCUR r I GAMS MADE MUCTBLE RETENTION s EACH OCCUR $ AGGREGATE $ S S s A MloaGER11 COMPEIIAnoN AND EMPLOYERWPRTOR� LIABILITY ANY OFIDICERIMEMBER■yss,tlw�+iEe��? SPELULPRO WWw -- 4073979 - - 10/01/04 10/01/05 X ITWLAM9 I I el ELEACIIAOC[IE/f s 100000 E.L. DISEASE -EA EMPLOYEE5100000 F-LDLSEASE-POUCYUW $500000 OTHwt DESCRIPTION OF OPIRATION8 I LOCATIONSIVEICLES; I NXCUM ONS ADDS) BY ENDORSEMENT I SPEC" PROVISIONS City of Ft. Collins Operations Service Department Attn: Frank Martinez 835 Wood St Ft. Collins CO 80522 CI'PYFOl I SHOULD AIRY OF THE ABOVE OESCMW POLICIES BE CANCELLED SOMME THE EX RMTIC ORTE THwAw THE mom LHamm Ual EHDEAYOR To MAR 30 DAYS WRITTEN NOTICE TO THE CIRTIPWATE HOLDEL NAM® TO THE LEFT, BUT FAILURE TO DO SO SHAM OR LIABILITY OF ANY KIND UPON THE ULSURNL, ITS AGENTS OR Form W-9 Request for Taxpayer (Rev. December Department or the Treasury Identification Number and Certification Internal Revenue Service Name (See Specific Instructions on page 2.) Give form to the requester. Do not send to the IRS. m a Bt151n ss name, if diff ant from abov . (See Specific Instructions on page 2.) oo-EIS-FLOrA1510(9 Sf�JI'X •� Check appropriate box: El Individual/Sole proprietor ©'Corporation 1:1 Partnership CD Other ►-------------------------------------- a v Requester's name and address (optional) Address (number, street, and apt. or suite no.l a q 40U--I N3007 'ST. City, state, and ZIP code FF. (1—Du1.-( N3-s )S21 Number Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part 1 instructions on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. List account numbers) here (optional) Social security number or For U.S. Payees Exempt From Backup Withholding (See the Employer identification number instructions on page 2.) Szzz z4 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and vidends ou are not required to sign the Certification, but you must provide your correct TIN. (See the instructions rage 2.) e Sign I ► ` Signature of T 7 ( /� Here U.S. person / (� Date ► Purpose of Form A person who is required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S, person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If you are a foreign person, use the appropriate Form W-8. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations. Note: If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. What is backup withholding? Persons making certain payments to you must withhold and pay to the IRS 31 % of such payments under certain conditions. This is called "backup withholding." Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions. rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, or 2. You do not certify your TIN when required (see the Part III instructions on page 2 for details), of 3. The IRS tells the requester that you furnished an incorrect TIN, or 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the Part II instructions and the separate Instructions for the Requester of Form W-9. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINS. If the requester discloses or uses TINS in violation of Federal law, the requester may be subject to civil and criminal penalties. Cat. No. 10231X Form W-9 (Rev. 12-2000)