The URL can be used to link to this page

Home My WebLink AboutDON KEHN - INSURANCE CERTIFICATE (8)ACORU. CERTIFICATE OF LIABILITY INSURANCE 1DATE 1/0303DrcryY) 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., ft600N 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. INSURER B: Pinnacol Assurance 31194 6550 SCRS INSURER C: Fort Collins, CO 80528 ."Ql I.= n. 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. LTR N R TYPE OF INSURANCE POLICY NUMBER POLICY TEYMFDDTIVE POLITE EXPIRATION LIMITS A X GENERAL LIABILITY 0161E88931ND03 11/01/03 11/01/04 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDnre $ CLAIMS MADE O OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 OQO OOO X Blkt Add[ Insrd X Ltd Pollution GENERAL AGGREGATE $2 000 OQO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2 OOO OOO Poucv X JECOT 7 LOC Fire Damage 300,000 A AUTOMOBILE X LIABILITY ANY AUTO 810161E8893TIL03 11/01/03 11/01/04 COMBINED SINGLE LIMIT (Ea accident) $1 r000 rOOO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS NON-OWNEDAUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY. AGG A EXCESS/UMBRELLA LIABILITY UP161 E8893TIL03 11/01/03 11/01/04 EACH OCCURRENCE $2 000 000 X OCCUR CLAIMS MADE AGGREGATE $2 OOO OOO $ DEDUCTIBLE $ X RETENTION $ 10000 B WORKERS COMPENSATION AND 2093950 10/01103 10101/04 TH- LIMITATU�j OFIR B EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE 2093950 10/01/03 10/01/04 E.L. EACH ACCIDENT $500000 E.L. DISEASE - EA EMPLOYEE $500OOO OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 11500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description: Furnishing Asphalt Certificate Holder is an Additional Insured as respects to General Liability only if required by written contract and coverage applies only as respects ongoing operations performed by Insured for the Certificate (See Attached Descriptions) City of Ft. Collins ATTN: Director of Purchasing & Risk Management P. O. Box 580 Ft. Collins, CO 80522-0580 LO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'An* 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 AUTHORIZED ^1 vmw LB(LOOIrVOIl OTS 951aJ91U/M1S3arV MA5 v A%,umu VVKYVKAIRJK lSOo 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. ACORD25-S(2001108% 1 nf4 *Q4Q101n1U4R1R70 DESCRIPTIONS (Continued from Page 1) Holder. All coverage terms, conditions and exclusions of the policy apply. . Except 10 Days Notice for Non -Payment of Premium and Workers Compensation for any cause of cancellation. AM$ 25.3 (2001108) 3 of 3 r-ua.,rtt- 91172 DONKFHNI ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE 11/03/030nrrv) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado 720 S. Colorado Blvd., #600N 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 Kahn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 INSURERS: Pinnacol Assurance 31194 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM DD POLICY EXPIRATION DATE M DDNY LIMITS A GENERAL LIABILITY O161E88931ND03 11/01103 11/01/04 EACH OCCURRENCE $1 000 000 DAMAGE TO RENTEDPREMISES (Ea occurrence) $ X = I COMMERCIAL GENERAL LIABILITY MADE 51 OCCUR MED EXP (Any one person) $5 000 PERSONAL&ADVINJURY $1 000 000 VLtCLAIMS XBIkt Addllnsrd d Pollution GENERAL AGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS, COMP/OP AGG $2 000 000 POLICY X EC LOG Fire Dama a 300 000 A AUTOMOBILE LIABILITY ANY AUTO 810161E8893TIL03 11/01/03 11/01/04 COMBINED SINGLE LIMIT (Ea accident) $1000 r ,000 X BODILY INJURY (Per parson) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X 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 EXCESS/UMBRELLA LIABILITY UP161E8893TIL03 11/01/03 11/01104 EACH OCCURRENCE s2,000,000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ FDEDUCTIBLE $ X RETENTION $ 10000 B WORKERS COMPENSATION AND 2093950 10/01l03 10/01l04 I)( YrC STATU- OTH- B EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 2093950 10/01/03 10/01/04 E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE $500000 OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Project Description: Mining Reclamation Agreement regarding ARapahoe Bend Natural Area. (See Attached Descriptions) City of Ft. Collins PO Box 580 Fort Collins, CO 80522-0580 ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL In* DAYS WRITTEN :E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ME NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE AL.UKU ZO (ZUUTIUU) 1 of 3 #S183909/M783879 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 #S183909/M183879 DESCRIPTIONS (Continued from Page 1) 1 Project Number: Certificate Holder is an Additional Insured as respects to General Liability only if required by written contract and coverage applies only as respects ongoing operations performed by Insured for the Certificate Holder. All coverage terms, conditions and exclusions of the policy apply. Except 10 Days Notice for Non -Payment of Premium and Workers Compensation for any cause of cancellation. AMS 25.3 (2001/08) 3 of 3 ##S1839091141183879