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HomeMy WebLinkAboutFIRST NATIONAL OF NEBRASKA - INSURANCE CERTIFICATE (6)RCORP CERTIFICATE OF LIABILITY INSURANCE DATE PRODUCER (303)980-0220 FAX (303)980-1610 THE BURGESS AGENCY, INC. 9100 WEST JEWELL AVE #100 P.O. BOX 150037 LAKEWOOD, CO 80215-0037 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 Foutch & Foutch, Inc. 5951 W. 26th St. Greeley, CO 80634 INSURERA: National Fire & Marine INSURERB: Interstate Indemnity wsuRERC: Pinnacol Assurance 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 ADUL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE IMWQDfYYI POLICY EXPIRATIONDATE DATE fMWDDfYYI LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE O OCCUR 72LP165894 10/25/2004 10/25/2005 EACH OCCURRENCE $ 2,000,00 DAMAGE TO RENTED $PREMIqF 100,000 $ 5 r 00 MED EXP (Any one person) PERSONAL & ADV INJURY $ 1 r 060 1 00 GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: P0LICYF_j PROJECT LOC PRODUCTS - COMP/OP AGG $ 2,000,00( B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS TP6117540 02/07/2004 02/07/2005 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR ❑ CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIA&LITV ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 4067254 04/01/2004 04/01/2005 X I we STArU- OTH- E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES i EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS City of Fort Collins 215 N. Mason 2nd Floor Fort Collins, CO 80S22 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 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 INS AUTHORIZED REPRESENTATIVE ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2001/08) ©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 (2001/08)