HomeMy WebLinkAboutQWEST - INSURANCE CERTIFICATE (4)a
PRODUCER
`S� 2 h fimmimggn
Marsh USA Inc.
Financial CenterON
4th Avenue
Suite #2300
CERTI FICATE NUMBER i
�2':��,5 i
I� ^..a.,:h . 4.. ;'..i.. ", k §.'.::"; F h,. r.s SEA 000659690-03
ATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERSThe
THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE1215
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE THE POLICIES DESCRIBED HEREIN.
Seattle, WA 98161-1095
Attn: Kathy B. Hariri 206 613-2625 Fax: 206 613-2516
COMPANIES AFFORDING COVERAGE
COMPANY
A NATIONAL UNION FIRE INS CO OF PA
100535-CAA-GAW-04-05 kbh 050804
INSURED
COMPANY
QWESTINTERMERICA,INC. g INSURANCE COMPANY OF THE STATE OF PA
1801 California Street
Street
Suite 1150 COMPANY
Denver, CO 80202 C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D
gp �yy 4ry�3�:py iryV: 'y yj3 5 y y
8 3 FLv'_ d d�i$-.:�' '+'!A]..:.43�v M1. 0..nS �vi :., -WP^.vT. n •F "+2. _:lir' i'ILi3 h 4k.%" .v'r+:4... .d+.Pi.�;:i, i :F, 5j'
THIS IS TO CERTIFYTHAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED SYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MMIDD/YY)
POLICY EXPIRATION
DATE (MMIDD/YY)
LIMITS
A
X
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE ❑X OCCUR
GL4806219
04/01/04
04/01/05
GENERAL AGGREGRATE
$ 1,000,000
PRODUCTS-COMP/OPAGG
$ 1,000,000
=
PERSONAL & ADV INJURY
$ 1,000,000
OWNER'S & CONTRACTOR'S PROT
EACH OCCURRENCE
$ 1,000,000
FIRE DAMAGE (Any one fire)
$ 1,000.000
MED EXP (Any one Person)
$ 5.000
A
AUTOMOBILE LIABILITY
AL5188917 (AOS)
04/01/04
04/01/05
A
X
ANY AUTO
AL5188918(LA, MN)
D4/01/04
04/01/05
COMBINED SINGLE LIMIT
$ 1.000,000
A
A
ALL OWNED AUTOS
SCHEDULED AUTOS
AL5188919 (MD, NY)
AL5188920(TX)
04/01/04
04/01/04
04/01/05
04/01/05
BODILY INJURY
(Per Person)
$
A
X
X
HIRED AUTOS
NON -OWNED AUTOS
AL5188921 (VA)
04/01/04
04/01/05
BODILY INJURY
(Per accident
$
X
SELF -INSURED FOR
PROPERTY DAMAGE
$
AUTO PHYSICAL DAMAGE
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
ANYAUTO
OTHER THAN AUTO ONLY:
%mil I 'rsi;,'j '�j ';t:i�1, i;R
EACHACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
UMBRELLA FORM
AGGREGATE
$
B
B
A
A
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
WC5212412 (AIDS)
WC5212411 (CA)
WC5212413(UT NO OH WI WV WY)
WC5212415 (OR)
04/01/04
04/01/04
04/01l04
04/01/04
04/01/05
04101/05
04/01/05
04/01/05
X I WC STATU- OTH-
TORVLIMITS ER
EL EACH ACCIDENT
$
fir....I s;;... .......s; lfil;;a
';: illiA
$ 1,000,000
EL DISEASE -POLICY LIMIT
$ 1,000,000
EL DISEASE -EACH EMPLOYEE
$ 1,000,000
OTHER
C
Excess Workers' Compensabon
WC5212414 (WA)
04/01/04
04/01/05
SIR Each Accident/Employee $1,000,000
Excess of SIR Shown Above $1,000,000
DESCRIPTION OF OPERATONS/LOCATIONSNEHICLES/SPECIAL ITEMS
RE: OMR #72608 . backup for City on Nortel equipment maintenance (4/211W to 5/8/04). The City, its officers, agents and employees are Additional Insureds as respects their
Interest in the operations of the Named Insured as required by written contract regarding General Liability.
a 3 3
F i l hh 11 �y§ s 1"v. 3 k3 - ,^¢y ,3ry.' Iy, 5, 4� .. 3 ,jay'.:' ,y4 yj Vey
i
';i "i.t :.a. .v3 'i4 i4i .di.?�: .ry'v.Y ih"Li ?. 3i 3. 'hyr.4 .}y 3M1i.:.hF r. .. :. .v.r 34.33_*ir4i4 d3::'yi .i.li?�wi'vF'..
;3 G._...
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION
City of Fort Collins DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS
Attn: Jeri Mae] WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH
PO Box 580 NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER
Fort Collins, CO 80522 AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS
CERTIFICATE.
MARSH USA INC
By Meg Lucia
rila3
,may n� rr�v4 3,
'S. -.ry3 S ggim S ..3 04I0t/04 Rom.
ji , _.: .I ,'.. ,.. z;� x z.,. _; hh:':4 th +�'.t„",.,. �', VALID,AS OF.
a _:: c. 3: 3 h: •4'i 4 .f4i h. �+.; r �" t:'. .+.. 3 _ .. _; Li:§ 't� 3 i