HomeMy WebLinkAboutBLUE ENERGY TECHNOLOGIES - INSURANCE CERTIFICATE (2)OP J DATE(MM/DD YIYY)
•'ACORD CERTIFICATE OF LIABILITY INSURANCE
PIC230A 1 11 23 04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dodge Warren 6 Peters -Torrance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Lic . #0543895 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
3625 Del Amo Blvd., #300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Torrance CA 90503-
Phone:310-542-4370 Fax:310-542-1803 INSURERS AFFORDING COVERAGE NAIC#
INSURED Blue Energy & Technologies,LLC INSURER A: Federal Insurance Company
Natural Fuels INSURER B: Great American ins. Companies
Clean Ener Fuels
Barbara Johnson INSURER C.
3020 Old Ranch Pk STE 200 INSURER
Seal Beach CA 9074�
INSURER E:
:9(01vI * F7n1d *.I
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.
IN*
LTR
AWU
INSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MWDD/YY
POLICY EXPIR
DATE MMIDDm N
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE "* OCCUR
35816898
11/30/04
11/30/05
PREMISES (Ea omurence)
$ 100,000
MED EXP (Any one person)
$ 10,000
PERSONAL 8 ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG
$ 1,000,000
POLICY PRO-
JECT X LOC
A
AUTOMOBILE
LIABILITY
ANY AUTO
73521990
11/30/04
11/30/05
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
X
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
X
HIREDAUTOS
NON -OWNED AUTOS
BODILY INJURY
(Per accident)
$
X
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHERTHAN EAACC
$
ANY AUTO
$
AUTO ONLY: AGG
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
$ 10,000,000
B
X OCCUR 1-1CLAIMSMADE
TUU3579326
11/30/04
11/30/05
AGGREGATE
$10,000,000
$
DEDUCTIBLE
RETENTION $N/A
$
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
71710119
11/30/04
11/30/05
X TORY LIMITS ER
E.L. EACH ACCIDENT
_
$ 1 000 000
E.L. DISEASE - EA EMPLOYEE
$1 000 000
OFFICER/MEMBER EXCLUDED?
I( yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$1 000 000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
*10 days notice IF for non-payment of premium. CITY OF FORT COLLINS IS
ADDITIONAL INSURED BY CONTRACT FOR SERVICES AGREEMENT - CNG FUELING
FACILITY AT FORT COLLINS, CO.
C-FTCOL
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 * 30 DAYS WRITTEN
PURCHASING
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
ATTN :
B. O' NEILL II
P.O.
58
BOXOX 580
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
FORT
COLLINS CO 80522
REPRESENTATIVES.
AUTHORIZED REPRESENT
1 ti,
Hk'umu LO tzuullua) _ — / U ACORD CORPORATION 1988
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.