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Home My WebLink AboutDON KEHN CONSTRUCTION - INSURANCE CERTIFICATE (5)ACORD,a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 07112105 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 Ste 600-N 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 # Don Kahn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 COVERAGES INSURER A: I revelers maemnity tNSURERB: Pinnacol Assurance 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 (MMIDDrYY1 POLICY EXPIRATION QATE4MMIDD(YYILIMITS A GENERAL LIABILITY 161E8893IND04 11/01/04 11/01/05 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED a300 000 CLAIMS MADE OR OCCUR MED EXP (Any one Person) $10 000 PERSONAL & ADV INJURY $1 000 000 AI# CG02520103 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY R� X XjLOC A AUTOMOBILE LIABILITY ANY AUTO 161EB893TIL04 11/01/04 11/01/05 COMBINED SINGLE LIMIT (Ea accident) E1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ 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 EXCESSIUMBRELLA LIABILITY 161E8893TIL04 11/01/04 11/01/05 EACH OCCURRENCE s2000000 TOCCUR CLAIMS MADE AGGREGATE s2,000,000 E $ ODEDUCTIBLE $ X RETENTION $ 10 000 B WORKERS COMPENSATION AND 2093950 10/01/04 10/01/05 X WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERlEXECUTIVE E.L. EACH ACCIDENT $500000 E.L. DISEASE- EA EMPLOYEE $500000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500 000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS REVISED CERTIFICATE: All previously Issued certificates are null and void for this Certificate Holder/Project. Project Description: Bid #5893/Drake/Ziegler Improvement Project (See Attached Descriptions) City of Fort Collins Administrative Services Purchasing Division P O Box 580 Fort Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL sn• 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 AL,UKN LO ILUUl/UU) 1 Of 3 0525805U)M257553 MAS Ly AGVKU GVKYVKAI IVK 7StlO 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 25S (2001/08) 2 of 3 #S258050/M257653 DESCRIPTIONS (Continued from Page 1) 1 The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects work performed by the Insured for the Additional Insureds. All coverage terms, conditions and exclusions of the policy apply. Additional Insureds: City of Fort Collins. The Additional Insured endorsement which is referenced above under "Type of Insurance -General Liability" is attached. * The following cancellation conditions always apply: -10 days for non-payment of premium - If policy shown, 10 days for Workers' Compensation for fraud; material misrepresentation; non-payment of premium; other reasons approved by the Commissioner of Insurance AMS 25.3 (2001103) 3 of 3 #5256050IM257653 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS OPERATIONS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY — CONTRACTORS COVERAGE PART 1. WHO IS AN INSURED — (Section 11) is amended c) This insurance does not apply to "bodily in- to include any person or organization you are re- jury" or "property damage" caused by "your quired to include as an additional insured on this work" included in the "products -completed policy by a written contract or written agreement operations hazard". in effect during this policy period and signed and d) This insurance does not apply to any person executed by you prior to the loss for which cover- or organization for whom you have procured age is sought. The person or organization does separate liability insurance while such insur- not qualify as an additional insured with respect to ance is in effect, regardless of whether the the independent acts or omissions of such person scope or limits of insurance in this policy ex - or organization. The person or organization is ceed those of such other insurance or only an additional insured with respect to liability whether such other insurance is valid or col - caused by "your work" for that additional insured. lectable. 2. The insurance provided to the additional insured 3. Subpart (1)(a) of the Pollution exclusion under is limited as follows: Paragraph 2., Exclusions of Bodily Injury and a) In the event that the limits of liability stated in Property Damage Liability Coverage (Section I — the policy exceed the limits of liability required Coverages) does not apply to you if the "bodily — by a written contract or written agreement in �= injury' or "property damage" arises out of "your effect during this policy period and signed and work" performed on premises which are owned or executed by you prior to the loss for which rented by the additional insured at the time "your "= coverage is sought, the insurance provided work" is performed. by this endorsement shall be limited to the 4. Any coverage provided by this endorsement to an m_ limits of liability required by such contract or additional insured shall be excess over any other agreement. This endorsement shall not in- valid and collectible insurance available to the o— crease the limits stated in Section III — LIMITS additional insured whether primary, excess, con- o OF INSURANCE. tingent or on any other basis. m_ b) The insurance provided to the additional in- 5. As a condition of coverage, each additional g sured does not apply to "bodily injury", "prop- insured must: erty damage", "personal injury" or "advertising injury" arising out of an architect's, engineer's a.) Give us prompt written notice of any "occur - = _ s rendering of or failure to render �— or surveyor rence" or offense which may result in a claim any professional services including: and prompt written notice of "suit". = I. The preparing, approving or failing to b.) Immediately forward all legal papers to us, o= prepare or approve maps, shop drawings, cooperate in the investigation or settlement of —_ opinions, reports, surveys, field orders, �= the claim or defense against the "suit," and change orders, or drawings and specifi- otherwise comply with policy conditions. cations; and c.) Tender the defense and indemnity of any u—_ 11. Supervisory or inspection activities per- claim or "suit" to any other insurer which also formed as part of any related architectural insures against a loss we cover under this or engineering activities. endorsement. This includes, but is not limited to, any insurer which has issued a policy of insurance in which the additional insured CG D2 52 01 03 Copyright, The Travelers Indemnity Company, 2003 Page 1 of 2 008543 ,COMMERCIAL GENERAL LIABILITY qualifies as an insured. For purposes of this that the insurer provide the additional insured requirement, the term "insures against' refers with a defense and/or indemnity under that to any self-insurance and to any insurer which policy of insurance. issued a policy of insurance that may -provide d.) Agree to make' available any other insurance coverage for the loss, regardless of whether that the additional insured has for a loss we the additional insured has actually requested cover under this endorsement. Page 2 of 2 Copyright, The Travelers Indemnity Company, 2003 CG D2 52 01 03