HomeMy WebLinkAboutFOUNDERS BUSINESS SERVICES AMCHECK - INSURANCE CERTIFICATE (2)A OR CERTIFICATE OF LIABILITY INSURANCE DATE (MIND
PRODUCER 1-303-534-4567 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The INA Financial Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
INA of Colorado, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1550 17th Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 600
Denver, CO 80202 INSURERS AFFORDING COVERAGE
INSURED INSURER A: Pinnacol Assurance
Founders Business Services LLC dba AmCheck
INSURER B:
1799 Pennsylvania Street INSURERC:
Denver, CO 80203 INSURER D:
C/IVV0AnIcQ
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
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
(MMIDDfM
POLICY EXPIRATIONDATE
DATE (MM1DD1YY)
LIMITS
GENERAL LIABILITY
EACHOCCURRENCE
$
FIRE DAMAGE (Any one fire)
$
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE1:1 OCCUR
MED EXP (Anyone person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS-COMP/OP AGG
$
POLICY PIFr.TRO LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHERTHAN EA ACC
$
ANY AUTO
$
AUTO ONLY: AGG
EXCESS LIABILITY
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION AND
4044899
06/01/04
06/01/05
WCSTATU- I OTH-
X LIM
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT
$ 100, 000
E.L. DISEASE - EA EMPLOYE
$100,000
E.L. DISEASE- POLICY LIMIT
$ 500, 000
OTHER
f
5
5
DESCRIPTION OF OPERATIONS/LOCATIONSNENICLESIEXCLUSIONS ADDED BY EHDORSEMENT/SPECIAL PROVISIONS
This Certificate shows that Hydro -Dynamic Services, L.L.C., 2207 Lake Ave., Eastlake, CO 80614 is covered under the
workers Compensation Policy issued to Founders Business Services LLC dba AmCheck.
City of Fort Collins
Box 580
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 DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Fort Collins, CO 80522
USA
ACORD 25S (7/971 charlie3
AUTHORIZED REPRESENTATIVE
269742E
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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.