Loading...
HomeMy WebLinkAboutDON KEHN - INSURANCE CERTIFICATE (7)ACORQ, CERTIFICATE OF LIABILITY INSURANCE 1DATE (MMID 0/29/04DfYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 S. Colorado Blvd Ste 600-N HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 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. INSURERB: Pinnacol Assurance 10780 6550 SCRS INSURER C: Fort Collins, CO 80528 INSURER D: INSURER E: rnVFRACFS 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' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MM/DDIYY LIMITS A GENERAL LIABILITY 161EB893IND04 11/01/04 11/01/05 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES (Ea occurrence) a300 000 CLAIMS MADE FX-I OCCUR MED EXP (Any one person) $10 000 PERSONAL& ADV INJURY $1 000 000 X Blkt Addl Insrd X Ltd Pollution GENERAL AGGREGATE 82 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 00O 000 POLICY X PRO- JECT X LOC A AUTOMOBILE LIABILITY ANY AUTO 161EB893TIL04 11/01/04 11/01/05 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESSIUMBRELLA LIABILITY 161E8893TIL04 11/01/04 11/01/05 EACH OCCURRENCE $2000000 X1 OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ DEDUCTIBLE $ X RETENTION $ 10 000 B WORKERS COMPENSATION AND 2093950 10/01/04 10/01/05 X WC STATU- OTH- ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $500000 E.L. DISEASE -EA EMPLOYEd $500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below I I E.L. DISEASE -POLICY LIMIT I $500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description: Ziegler Road Widening Bid Number: 5834 (See Attached Descriptions) City of Ft. Collins 215 North Mason Street, 2nd Floor Box 580 Fort Collins, CO 80522 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL sn* 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 ACORD 25 (2001108) 1 of 3 #M230290 MAS o 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. ACORD 25-S (2001/08) 2 of 3 #M230290 DESCRIPTIONS (Continued from Page 1) 1 if required by written contract and coverage applies only as respects 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 AMS 25.3 (2001/08) 3 of 3 #M230290 INSUMD: Don Kehn Construction, Inc. PC LILY KNIBEc2: 16 IE8893IIZ04 COMMERCIAL GENERAL LIABILITY T1HIS GKInnDS_EMDNT CJHANG_-Q TWI= DC)l ICY. PLEA D-nQ IT CAREFULLY 1 1 V L 1\✓ V 1\ V L. L 1 1 Y V L V 1 1 1 L 1 L 1 l L L l'R V L 1 1 L. ("1 1\ 1 IJ L 1 BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY— CONTRACTORS COVERAGE PART t. WHO IS AN INSURED — (Section II) is amended to include any person or organization you are re- quired to include as an additional insured on this policy 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 cover- age is sought. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The person or organization is only an additional insured with respect to liability caused by "your work" for that additional insured. 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- 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", 11prop- elty 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: I. 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 ll. Supervisory or inspection activities per- formed as part of any related architectural or engineering activities. 3. 4. c) This insurance does not apply to "bodily in- jury" or "property damage" caused by "your work" included . in the "products -completed operations hazard" unless you are required to provide such coverage for the additional in- sured by a written contract or written agree- ment in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought and then only for the period of time required by such con- tract or agreement and in no event beyond the expiration date of the policy. 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 th6 "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. 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. 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". Clianfl6. 21172 7�7:13d71a ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE 09/22104Drcrrv) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado 720 S. Colorado Blvd Ste 600-N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 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 Kehn Construction, Inc. 6550 SCRS Fort Collins, CO 80528 INSURER B: Pinnacol Assurance 10780 INSURER C: 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 NDD'L NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE AT M DD POLICY EXPIRATION DATE (MM1DDffY1 LIMITS A GENERAL LIABILITY DTCO161E88931ND03 11/01/03 11/01/04 EACH OCCURRENCE $1000000 DAMAGE TO RENTED s300OOD X COMMERCIAL GENERAL LIABILITY CLAIMS MADE 51OCCUR MED EXP (Any one parson) $1 D 000 PERSONAL & ADV INJURY $1 000 000 X Blkt Addl Insrd X Ltd Pollution GENERAL AGGREGATE s2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2009000 POLICY 7X PRO JECT X LOC A AUTOMOBILE LIABILITY ANY AUTO DT810161E8893TIL03 11/01/03 11/01/04 COMBINED SINGLE LIMIT (Ea accident) $1000 r r000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGO A EXCESSIUMBRELLA LIABILITY DTSMJCUP161E8893TI 11/01/03 11/01/04 EACH OCCURRENCE s2000000 X OCCUR 7 CLAIMS MADE AGGREGATE s2,000,000 $ FDEDUCTIBLE $ X RETENTION $ 10000 WORKERS COMPENSATION AND 2093950 10/01/04 10/01/05 TATB OTH- X WCSLIIT IR M EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $500000 E.L. DISEASE - EA EMPLOYEEI $500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description: Ziegler Road Widening Bid Number: 5834 The following are Additional Insureds as respects General Liability only (See Attached Descriptions) City of Ft. Collins 215 North Mason Street, 2nd Floor Box 580 Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -'An* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR AGUKU Z9 IIZUUIIUC) 1 of 3 #M223972 HXK © ACOKU CORPORATION 1935 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. ACORD 25-S (2001/08) 2 Of 3 #M223972 DESCRIPTIONS (Continued from Page 1) J if required by written contract and coverage applies only as respects 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 AMS 25.3 (2001108) 3 of 3 #M223972 P01icy Number: uDT-Co-16I 8893-IND--03 COMMERCIAL GENERAL LIABILITY Twlc END(OR�EnnEniT CHANGES THE POLICY. RLErA,SE READ IT CAREFULLY 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 ihsured 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 sir organization. The_eerson 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 heyond 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- 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: I. 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 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. As a condition of coverage, each additional insured must: il. Supervisory or inspection activities per- a.) Give us prompt Written notice of any "occur - formed as part of any related architectural rence" or offense which may result in a claim and prompt written notice of "suit". or enoineerine activities. 1 The i. I l 't �n c�.. c£1 (�:7 l Ca �_ _ _,, py is h., r . -: i;der1) 1 y 1 ,ly, G 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. ACORD 25-S (2001108) 2 of 3 #M230290 DESCRIPTIONS (Continued from Page 1) 1 The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects 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 AMS 25.3 (2001/08) 3 of 3 #M230290 INSURED: Don Kehn Construction, Inc. PCLICY NUMBER: 16IE8893IIM COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CH AN TuE opr ICv or cn ^G a�-An IT CAIREFULLY „�v � .vv�w�-, i ..a � ,.v�-.v „iC � �.. ,. � ��(-.vim i �i v 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 to include any person or organization you are re- quired to include as an additional insured on this policy 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 cover- age is sought. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The person or organization is only an additional insured with respect to liability caused by "your work" for that additional insured. 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 m_ 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- 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 N= or surveyor's rendering of or failure to render any professional services including: I. 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 II. Supenfisory or inspection activities per -formed as part of any related architectural or engineering activities. c) This insurance does not apply to "bodily in- jury" or "property damage" caused by "your work" included . in the "products -completed operations hazard" unless you are required to provide such coverage for the additional in- sured by a written contract or written agree- ment in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought and then only for the period of time required by such con- tract or agreement and in no event beyond the expiration date of the policy, 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. 5. 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". ACORD. CERTIFICATE OF LIABILITY INSURANCE 1DATE 0129/MIDDIYYYY) 0/29/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 S. Colorado Blvd Ste 600-N HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 469025 Denver, CO 80246-9025 INSURED Don Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 AGES INSURERS AFFORDING COVERAGE NAIC # INSURER A: Travelers Indemnity Company 25658 INSURERB: Pinnacol Assurance 10780 INSURER C: INSURER D: INSURER E: 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE O OCCUR X Blkt Addl Insrd 161E88931ND04 11/01/04 11/01/05 EACH OCCURRENCE $1000000 DPREMISE Ea occurrence) AMAGE TO RENTED $300 000 MED EXP (Any one person) $10O00 PERSONAL&ADV INJURY $1 00O 000 X Ltd Pollution GENERAL AGGREGATE s2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECOT X LOC PRODUCTS-COMPlOP AGG s2,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Ltd Pollution 161E8893TIL04 11/01/04 11/01/05 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHERTHAN EA ACC AUTO ONLY: AGG $ $ A EXCESSIUMBRELLA LIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE X RETENTION $ 1O 000 161E8893TIL04 11101/04 11/01/05 EACH OCCURRENCE $2 00O 000 AGGREGATE s2,000,000 $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 2093950 10101/04 10/01/05 X WC STATU- OTH- E.L. EACH ACCIDENT $5OO 000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: Mining Reclamation Agreement regarding Arapahoe Bend Natural Area (See Attached Descriptions) u= City of Ft. Collins PO Box 580 Fort Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL �' n DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ACORD 25 (2001/08) 1 of 3 #M230290 MAS O ACURD GURPURA I ION TBBS 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. ACORD 25-S (2001108) 2 of 3 #M230290 DESCRIPTIONS (Continued from Page 1) 1 The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects 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 AMS 25.3 (2001/08) 3 of 3 #M230290 INSURED: Don Kehn Construction, Inc. PCLICY NUMBER: • 16 JE8893IIM COMMERCIAL GENERAL LIABILITY THS ENL�nR.Q.EMENT CH AN THE onLICY. o1 "ASE aEAn IT CAI EFULLv I IIV V I \V1..-1 VI I I V VLV I THE 1 V 1 LLI"IV L 1 \V. 1..! 1\ 1 6J 1 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 ihsured 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 or organization. The person 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 3. Subpart (1)(a) of the Pollution exclusion under is limited as follows: Paragraph 2., Exclusions of Bodily Injury and _ a) In the event that the limits of liability stated in Property Damage Liability Coverage (Section I — "bodily Coverages) does not apply to you if the the policy exceed the limits of liability required injury" or "property damage" arises out of "your — by a written contract or written agreement in work" performed on premises which are owned or effect during this policy period and signed and rented by the additional insured at the time "your "- executed by you prior to the loss for which work" is performed. "= coverage is sought, the insurance provided �— by this endorsement shall be limited to the 4. Any coverage provided by this endorsement to an limits of liability required by such contract or additional insured shall be excess over any other o= agreement. This endorsement shall not in- valid and collectible insurance available to the o= crease the limits stated in Section III — LIMITS additional insured whether primary, excess, con- OF INSURANCE. tingent or on any other basis unless a written �^ contract or written agreement in effect during this - b) The insurance provided to the additional in- "bodily "prop- policy period and signed and executed by you m= sured does not apply to injury", 1 I prior to the loss for which coverage is sought „ „ — erty damage", personal injuryor advertising �— I specifically requires that this insurance apply on a injuryarising out of an architects, engineers primary or non-contributory basis. When this in - or surveyors rendering of or failure to render �= surance is primary and there is other insurance any professional services including: available to the additional insured from any —_ I. The preparing, approving or failing to source we will share with that other insurance by —= prepare or approve maps, shop drawings, the method described in the policy. _= opinions, reports, surveys, field orders, change orders, or drawings and specifi- 5. As a condition of coverage, each additional cations; and insured must: IL Supervisory or inspection activities per- a.) Give us prompt written notice of any "occur which may result in a claim = formed as part of any related architectural rence" or offense and prompt written notice of "suit". or engineering activities. ACQRD- CERTIFICATE OF LIABILITY INSURANCE 10129/04DIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 S. Colorado Blvd Ste 600-N HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 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 Kehn Construction, Inc. INSURERB: Pinnacol Assurance 10780 6550 SCR5 INSURER C: Fort Collins, CO 80528 INSURERD: INSURER E: rnveoerscc 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 ROD' N R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM DD POLICY EXPIRATION DATE MM D LIMITS A GENERAL LIABILITY 161E88931ND04 11/01/04 11/01/05 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES (Ea occurrence) $300 OOO CLAIMS MADE 51OCCUR MED EXP (Any one person) $10 000 PERSONAL & ADV INJURY $1 000 000 X Blkt Addl Insrd X Ltd Pollution GENERAL AGGREGATE $2 000 000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY X PEOT X LOC A AUTOMOBILE LIABILITY ANY AUTO 161E8893TIL04 11/01/04 11/01/05 COMBINED SINGLE LIMIT (Ea accident) $1r000 ,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULEDAUTOS X BODILY INJURY (Per accident) $ HIREDAUTOS NON-OWNEDAUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTOONLY: AGG A EXCESSIUMBRELLALIABILITY 161E8893TIL04 11/01/04 11/01/05 EACH OCCURRENCE $2000000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ DEDUCTIBLE Fx]RETENTION $ $ 10 000 B WORKERS COMPENSATION AND 2093950 10101/04 10/01/05 X WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500OOO E.L. DISEASE - EA EMPLOYEE $500,000 OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below I E.L. DISEASE - POLICV LIMIT $500,000 OTHER :I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: Furnishing Asphalt The following are Additional Insureds as respects General Liability only (See Attached Descriptions) City of Ft. Collins ATTN: Director of Purchasing & Risk Management P. O. Box 580 Ft. Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL sn* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ACORD 25 (2001/08) 1 of 3 #M230290 MAS 0 ACORD CORPORATION 1988