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HomeMy WebLinkAboutDELTA CONSTRUCTION - INSURANCE CERTIFICATE (2)ACORD�, CERTIFICATE OF LIABILITY INSURANCE 04/30/2004 04/30/2004 PRODUCER (303)939-9921 FAX (303)939-9926 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Herbert -Leavitt Longmont ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 275 South Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 208 Longmont, CO 80501 INSURED Delta Construction, In 208 Raquette Dr Fort Collins, CO BOS24 INSURERS AFFORDING COVERAGE INSURERA: Travelers INSURERS: Pinnacol Assurance INSURER C: INSURER D: INSURER E: NAIC 0 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW ITHSTANDINI 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 D' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIODNYI POLICY EXPIRATION DATE (MMIDDNYI 04/30/2005 LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE I I OCCUR DTC0384P7423IND03 04/30/2004 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED (Fa..) $PREMISE 300,00 11 MED EXP (Any one person) $ S,00( PERSONAL & ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,00( AUTOMOBILE LIABILITY ANY AUTO OT810384P7423TIL03 04/30/2004 04/30/200S COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 X BODILY INJURY (Per person) $ A ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESSIUMBRELLALIABILITY X OCCUR CLAIMS MADE DTSMCUP384P7423TIL03 04/30/2004 04/30/200S EACH OCCURRENCE $ 3,000,00 AGGREGATE $ 3,000,000 A $ DEDUCTIBLE X RETENTION $ 10 , 0O $ WORKERS COMPENSATION AND 3299114 07/01/2003 07/01/2 004 X I WCSTATU- I OTH- EMPLOYERS' LIABILITY TORY E.L. EACH ACCIDENT $ S00,000 B ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? H yes describe under SPECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE $ 500, 00 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS e: City of Fort Collins -Moss Rock Wall Certificate holder is named as additional insured. City of Fort Collins Attn: James B O'Neill II, CPPO, FNIGP 215 N Mason 2nd F1 Fort Collins, CO 80521 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Kelly McNair/KDM AGUKU ZO (ZUUTIUtl) ©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. AUUKU ZO (ZUUINtl) ACORD. CERTIFICATE OF LIABILITY INSURANCE 04/30//i 0 ) PRODUCER (303)939-9921 FAX (303)939-9926 Herbert -Leavitt Longmont 275 South Main Street Suite 208 Longmont, CO 80501 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 Delta Construction, Inc 208 Raquette Or Fort Collins, CO 80524 INSURERA: Travelers INSURERB: Pinnacol Assurance 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. NOTWITHSTANDINI 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 ADD'L um TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE iMMIDDIYYI POLICY EXPIRATIONim DATE (MM1DrI/YYI 04/30/2005 LIMITS GENERALLIASILITY DTC0384P7423INDO3 04/30/2004 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,00( CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5,00( A PERSONAL & ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000.00 AUTOMOBILE LIABILITY ANY AUTO DT810384P7423TIL03 04/30/2004 04/30/200S COMBINED SINGLE LIMIT (Ea aaident) $ 1,000,00 X BODILY INJURY (Per person) $ A ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per aaident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per aaident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY X I OCCUR CLAIMS MADE DTSMCUP384P7423TIL03 04/30/2004 04/30/2005 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 A $ DEDUCTIBLE X RETENTION $ 10,00 WORKERS COMPENSATION AND 3298114 07/01/2003 07/01/2004 X WC srATu- OTH- - EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ S00,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? S yes, describe under ECIAL PROVISIONS below SP E.L. DISEASE - EA EMPLOYE $ SDQ, OD E.L. DISEASE - POLICY LIMIT $ SDD, 00 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS e: Old Town Square Restrooms ertificate holder is named as additional insured. City of Fort Collins c/o Purchasing 215 N Mason 2nd Fl Fort Collins, CO 8OS21 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESI AUTHORUED REPRESENTATIVE I'1'I r Kelly McNair/KDM 1 �� ACORD 25 (2001108) ©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. AGORD 25 (2001108)